Frontoparietal Area Research Articles

Frontal Linear Scleroderma

Frontal linear scleroderma (also known as "en coup de sabre") is a congenital deformity characterized by a linear band of atrophy and a furrow in the skin that occurs in the frontal or frontoparietal area. The authors present a case of a 34-year-old woman with history of en coup de sabre. In different steps, volumetric restoration of the fronto-orbital region has been obtained by structural fat grafting technique. After 3 reconstructive surgeries, morphologic, functional, and aesthetic long-term results have been obtained.

Delayed ischemic stroke associated with bromocriptine-induced reversible cerebral vasoconstriction syndrome

Reversible cerebral vasoconstriction syndromes (RCVS) are a group of disorders characterized by prolonged but reversible vasoconstriction of the cerebral arteries, usually associated with acute-onset, severe, recurrent headaches, with or without additional neurologic signs and symptoms [1]. These syndromes are known to occur secondarily to the use of drugs such as cannabis, cocaine, ecstasy, amphetamine, selective serotonin-reuptake inhibitors (SSRIs) and nasal decongestants, or during pregnancy or the puerperal period itself [2]. RCVS which presents at puerperium is known as postpartum cerebral angiopathy (PCA) and is associated with the concomitant use of vasospastic drugs such as bromocriptine [3]. However, RCVS induced by bromocriptine beyond the puerperal period has not so far been reported. We describe here a case of bromocriptineinduced RCVS with ischemic stroke arising 1 year after the birth of second baby. A 32-year-old woman presented with an episode of transient left-sided weakness and dysarthria that lasted approximately 15 min, and a progressively worsening headache over several days. She had given birth to a second healthy baby 1 year before the present admission and it was uncomplicated as was her first pregnancy. Sixteen days before admission she had started on a course of 2.5 mg oral bromocriptine mesylate twice a day for 7 days to suppress lactation. After 7 days use of the bromocriptine, she was admitted to an outside hospital because of severe headache, transient left-sided weakness and dysarthria. At that time her vital signs were stable, including blood pressure of 130/85 mmHg and neurologic examination was unremarkable. Diffusion and fluid attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI) revealed focal high-signal areas in the right frontal lobe (Fig. 1a, b) and magnetic resonance angiography (MRA) showed up severe stenosis in both middle cerebral arteries (Fig. 2a). A transcranial Doppler (TCD) disclosed abnormally high flow velocities in both middle cerebral arteries, and a CSF examination was normal. Low-dose acetylsalicylic acid (100 mg once a day) was initiated on a suspicion of transient ischemic attack with right middle cerebral artery stenosis. The patient was referred to our hospital 9 days after the onset of her symptoms due to recurrent severe headache. Upon arrival, vital signs were stable including a blood pressure of 125/80 mmHg. The patient had severe headache without any abnormalities of neurologic examination. Laboratory examinations including renal function, urinalysis, international normalized ratio, partial thromboplastin time, thrombin time, antithrombin III, protein C, protein S, D-dimer, and fibrin monomers were unremarkable. In addition, tests for antinuclear and anticardiolipin antibodies, and complement indices were normal. On the second day in our hospital, her headache worsened with newly developed left-sided weakness and dysarthria. At that time, diffusion and FLAIR images demonstrated extended highsignal areas in the bilateral fronto-parietal area (Fig. 1c, d). Y. S. Kim W. Baek J. Kim H. Y. Kim Department of Neurology, College of Medicine, Hanyang University, Seoul, Republic of Korea

Spontaneous disappearance of an acute epidural hematoma with emergence of a contralateral subdural hematoma after traumatic brain injury

Epidural hematoma (EDH) is a common sequela of traumatic brain injury (TBI) and usually results in life-threatening brain compression, which warrants emergency surgical evacuation. Here we present an 85-year-old man who had a traumatic brain injury with an EDH in the right frontoparietal area. He was transferred to our hospital with deep coma status and follow-up computed tomography (CT) showed the EDH had spontaneously disappeared within 2 hours. Furthermore, a contralateral subdural hematoma had developed, which caused a midline shift. Rare cases of rapid spontaneous resolution of an EDH have been reported in the literature. In our patient, the EDH seemed to have been pushed out from the fractured skull because the hematoma would not coagulate due to an underlying coagulopathy. Repeat CT is imperative before surgery for acute TBI and for unconscious patients whose initial CT was performed within 3 hours of injury.

An Electroencephalographic Investigation of the Filled-Duration Illusion

The study investigated how the brain activity changed when participants were engaged in a temporal production task known as the “filled-duration illusion.” Twelve right-handed participants were asked to memorize and reproduce the duration of time intervals (600 or 800 ms) bounded by two flashes. Random trials contained auditory stimuli in the form of three 20 ms sounds between the flashes. In one session, the participants were asked to ignore the presence of the sounds, and in the other, they were instructed to pay attention to sounds. The behavioral results showed that duration reproduction was clearly affected by the presence of the sounds and the duration of time intervals. The filled-duration illusion occurred when there were sounds; the participants overestimated the interval in the 600-ms interval condition with sounds. On the other hand, the participants underestimated the 800-ms interval condition without sounds. During the presentation of the interval to be encoded, the contingent negative variation (CNV) appeared around the prefrontal scalp site, and P300 appeared around the parieto-central scalp site. The CNV grew larger when the intervals contained the sounds, whereas the P300 grew larger when the intervals were 800 ms and did not contain the sounds. During the reproduction of the interval to be presented, the Bereitschaftspotential (BP) appeared over the fronto-central scalp site from 1000 ms before the participants’ response. The BP could refer to the decision making process associated with the duration reproduction. The occurrence of three event-related potentials (ERPs), the P300, CNV, and BP, suggests that the fronto-parietal area, together with supplementary motor area (SMA), is associated with timing and time perception, and magnitude of these potentials is modulted by the “filled-duration illusion”.

Meningioma in a 20-Month-Old Boy

A 20-month-old boy presented with a intraparenchymal mass in the right frontoparietal area manifesting as complex partial seizure, secondary generalization and left hemiparesis. Magnetic resonance images (MRI) of the brain showed inhomogeneously enhancing mass in the right frontoparietal area which has irregular margin and perilesional edema. Based on the radiological findings, a preoperative diagnosis was an intraaxial tumor, such as pilocytic astrocytoma or dysembryoplastic neuroepithelial tumor. The patient underwent a surgery including frontal craniotomy. The tumor had a partially extreme adherence to the surrounding brain tissue but it showed no dural attachment. Gross-total resection of the tumor was achieved. Postoperative follow-up computed tomography scans showed no residual tumor. The pathological findings confirmed the tumor as a WHO grade I meningioma, transitional type. Nine months after the surgery, follow-up brain MRI showed no recurrence of the tumor, porencephaly in site where the tumor was resected; the patient's symptoms had fully recovered. We report the case of a meningioma in a 20-month-old boy.

Neurologic involvement in scleroderma en coup de sabre.

Localized scleroderma is a rare disease, characterized by sclerotic lesions. A variety of presentations have been described, with different clinical characteristics and specific prognosis. In scleroderma en coup de sabre (LScs) the atrophic lesion in frontoparietal area is the disease hallmark. Skin and subcutaneous are the mainly affected tissues, but case reports of muscle, cartilage, and bone involvement are frequent. These cases pose a difficult differential diagnosis with Parry-Romberg syndrome. Once considered an exclusive cutaneous disorder, the neurologic involvement present in LScs has been described in several case reports. Seizures are most frequently observed, but focal neurologic deficits, movement disorders, trigeminal neuralgia, and mimics of hemiplegic migraines have been reported. Computed tomography and magnetic resonance imaging have aided the characterization of central nervous system lesions, and cerebral angiograms have pointed to vasculitis as a part of disease pathogenesis. In this paper we describe the clinical and radiologic aspects of neurologic involvement in LScs.

Brain Activity during the Observation, Imagery, and Execution of Tool Use: An fNIRS/EEG Study

This study used a functional near-infrared spectroscopy (fNIRS)/electroencephalogram (EEG) system to investigate brain activity during a daily living situation where subjects are engaged in the observation, imagery, and execution of tool use. The subjects were 24 healthy adults who signed an agreement to participate in the present study. All subjects were right-handed according to the Edinburgh Handedness Inventory. The subjects sat on a chair and participated in the observation, imagery, and execution of chopstick and hammer movements. Each trial consisted of observation, imagery, and execution and the trials were performed in triplicate. The timing protocol was 15.0, 15.0, 15.0, 15.0, and 15.0 s for rest, task, rest, task, and rest, respectively, and brain activity was measured during these periods. fNIRS and EEG were used to measure brain activity. Optical fibers of fNIRS were positioned over the frontoparietal area. Oxyhemoglobin served as a parameter, and NIRS-statistical parametric mapping (SPM) was used for data analysis. EEG measurements were made using 32 electrodes with an international 10–20 system. The event-related desynchronization of the Mu frequency band (8-12 Hz) was calculated by power spectrum analysis. The brain regions activated during the imagery and execution of the chopsticks movement were the dorsolateral prefrontal cortex, inferior frontal gyrus, premotor cortex, and primary somatosensory cortex, while the mu ERD values were obtained under both conditions. The brain regions that were mainly activated under all three conditions of the hammer movement, i.e., observation, imagery, and execution, were the dorsolateral prefrontal cortex, inferior frontal gyrus, and premotor cortex, while the mu ERD values were obtained under all three conditions. These results suggest that brain activity during the observation, imagery, and execution of tool use differed according to the sensory modality linked to a tool.

Successful Treatment of Hemifacial Myokymia and Dystonia Associated to Linear Scleroderma “En Coup de Sabre” with Repeated Botox Injections

Linear scleroderma “en coup de sabre” (LSCS) is a form of localized scleroderma presents as band-like sclerotic lesions of the frontoparietal area. It has been reported in association with diverse neurological manifestations like seizures, migraine, neuromyotonia, dystonia and abnormalities in MRI and CT studies as cerebral atrophy, white matter lesions, intraparenchymal calcification, meningeocortical alterations, and skull atrophy. We describe a patient with LSCS associated with two abnormal movements: permanent myokimia of right masseter muscle and recurrent spasmodic retraction of right cigomatic and depressor labii inferioris muscles. He was initially treated with methotrexate and steroids without response, so later on he underwent repeated Botox injections with remarkable improvement.

Increases in Amplitude of Low-Frequency Fluctuations in Left Fronto-Parietal Area After Duloxetine Therapy in First-Episode, Drug-Naïve, Major Depressive Disorder With Panic Disorder Patients

Increases in Amplitude of Low-Frequency Fluctuations in Left Fronto-Parietal Area After Duloxetine Therapy in First-Episode, Drug-Naïve, Major Depressive Disorder With Panic Disorder Patients

Retinal hemorrhage as an initial sign of cerebral hyperperfusion syndrome after carotid artery stenting

Dear editor,In patients with carotid artery stenosis, cerebral reperfusionafter carotid artery revascularization, such as carotidendarterectomy (CEA) or carotid artery stenting (CAS),may cause cerebral hyperperfusion syndrome (CHS) [1, 2].If not treated properly, CHS can result in severe brainedema, intracerebral or subarachnoid hemorrhage, and evendeath. Therefore, early detection of CHS is of criticalimportance. We present a rare case of retinal hemorrhage asthe initial sign of CHS after CAS.A 62-year-old man was admitted because of amaurosisfugax involving his left eye and temporary right hemi-paresis. There was no high-signal intensity on the diffusion-weighted image (DWI). Trans-femoral cerebral angiogra-phy (TFCA) revealed severe stenosis (approximately 90%)of the left proximal internal carotid artery (Fig. 1a). Weconcluded that this was a symptomatic lesion so that CASwas performed under distal embolic protection without anycomplications (Fig. 1b). We did not evaluate cerebral bloodflow (CBF) measurement for this patient before performingCAS.The blood pressure (BP) of the patient was about 160/100 mmHg before the procedure and decreased to about120/80 mmHg in the post-stenting period. On the morningon the 3rd postoperative day, the patient complained ofblurred vision in his left eye with a left temporo-parietalheadache, and he became lethargic. Suspecting an intrace-rebral hemorrhage by CHS, a brain computed tomographywas obtained, which showed no specific findings. On theDWI, there was no evidence suggesting an acute infarction;however, the perfusion-weighted image showed shorteningof the mean transit time (MTT) and increased cerebralblood volume (CBV) in the left fronto-parietal area(Fig. 1c). Immediate reduction of the systemic arterialblood pressure was achieved with intravenous labetalol. Onthe next day, an ophthalmologic examination was per-formed. Retinal hemorrhage in the left lower quadrant ofthe macula was observed, which was the likely cause of theblurred vision (Fig. 1d). CHS was confirmed based onclinical symptoms, radiographic findings, and the results ofan ophthalmologic examination. On the 7th postoperativeday, a follow-up TFCA was performed, which showed theleft ophthalmic artery to be increased in size and densitycompared to the pre-stenting TFCA (Fig. 1e), suggestingthat the increased blood flow to the left ophthalmic arterymight cause retinal hemorrhage.The general clinical features of CHS include the triad ofipsilateral headaches, seizures, and neurologic impairment(ataxia, visual disturbance, focal limb weakness) unrelatedto thromboembolism, and without evidence of new infarc-tion. In this case, CHS was confirmed by clinical symptoms(ipsilateral headaches and visual disturbance) and radio-graphic findings (shortening of the MTT, increased CBV,and left ophthalmic artery increased in density and size).Retinal hemorrhage can be caused by chronic hypertension,retinal vein occlusion, retinal artery embolus, diabeticretinopathy, or trauma. The patient had a 10-year historyof hypertension and diabetes, which carries the possibilityof inducing retinal hemorrhage coincidentally. This possi-bility evoked doubt whether or not the retinal hemorrhage

Development of Mu Rhythm in Infants and Preschool Children

Mu rhythm is an idling rhythm that originates in the sensorimotor cortex during rest. The frequency of mu rhythm, which is well established in adults, is 8–12 Hz, whereas the limited results available from children suggest a frequency as low as 5.4 Hz at 6 months of age, which gradually increases to the adult value. Understanding the normal development of mu rhythm has important theoretical and clinical implications since we still know very little about this signal in infants and how it develops with age. We measured mu rhythm over the left hemisphere using a pediatric magnetoencephalography (MEG) system in 25 infants (11–47 weeks), 18 preschool children (2–5 years) and 6 adults (20–39 years) for two 5-min sessions during two intermixed conditions: a rest condition in which the hands were at rest, and a prehension condition in which the subject squeezed a pipette with his/her right hand. In all participants, mu rhythm was present over the frontoparietal area during the rest condition, but was clearly suppressed during the prehension condition. Mu rhythm peak frequency, determined from the amplitude spectra, increased rapidly as a function of age from 2.75 Hz at 11 weeks to 8.25 Hz at 47 weeks (r² = 0.83). It increased very slowly during the preschool period (3.1 ± 0.9 years; 8.5 ± 0.54 Hz). The frequency in these children was, however, lower than in adults (10.3 ± 1.2 Hz). Our results show a rapid maturation in spontaneous mu rhythm during the first year of life.

Insular cortex activation in a patient with "sensed presence"/ecstatic seizures

Objective Seizures with an aura of a "sensed presence," a religious emotion, or feelings of euphoria (ecstatic seizures) are characterized by heightened self-awareness. A previous case report on a patient with epilepsy and "sensed presence" as an aura described hypoperfusion in both temporal lobes and a local ictal increase in the left frontoparietal area. A reexamination of the data was suggested by a recent study of patients with ecstatic seizures, which proposed that hyperactivation of the left anterior insula might be a potential cause. Methods We reanalyzed the laboratory data on the case with "sensed presence" aura using a fusion of SPECT and MR images of the brain, which had not previously been available, and a close examination of the subdural ictal EEG registrations. Results Examination of the ictal EEG recordings from subdural strip electrodes implanted subtemporally and temporally on both sides showed that seizure activity occurred first at the most medial subtemporal electrode on the left side. From an anatomical point of view, this electrode position is close to the ventral aspect of the left anterior insula, and it is possible that the seizure activity was initiated there. Reexamination of the SPECT data after fusion with contemporary MR images clearly indicated that the region of strong hyperactivation overlies the left anterior insula. Hyperactive regions also appear on the midinsula bilaterally. Together with the neurophysiological ictal EEG, this evidence supports a reinterpretation that this aura of "sensed presence" can be attributed to hyperactivation of the left anterior insula. Conclusion The present findings support the proposal that ecstatic seizures or "sensed presence" auras can originate from the left anterior insula, a region that has been suggested to engender self-awareness associated with positive feelings.

A Tale of Two Tauopathies

A 77-year-old man developed progressive language and balance difficulties. He had difficulty rising from a chair, with falls occurring within the first year of symptoms. After 1 year, rapid, spontaneous jerks appeared in the left hand, which he described as “useless.” Neurologic examination 3 years after his initial symptoms demonstrated 23/30 on the Mini-Mental State Examination and an applause sign. He had apathy, without a pseudobulbar affect. Aside from mild word-finding difficulties, his language examination was normal. Cranial nerve examination showed vertical gaze limitation with loss of vertical fast phases on testing of optokinetic nystagmus (OKN). Vertical gaze limitations could be overcome with oculocephalic maneuvers. Motor examination revealed markedly increased tone in his left arm, with moderate left greater than right bradykinesia, without tremor. Left ideomotor apraxia was present. Action and postural myoclonus was present in the left arm. There was neck extension and axial rigidity. Gait was slow and slightly wide-based with impaired postural reflexes. Stereognosis and graphesthesia were intact. A trial of levodopa/carbidopa 900 mg per day showed no symptomatic benefit. Brain MRI without gadolinium revealed asymmetric, focal atrophy of the right frontoparietal area and the midbrain tegmentum (figure). Figure Brain MRI (A) Axial T1-weighted brain MRI shows atrophy of the …

Scrotal Migration of Lumboperitoneal Shunt Catheter in an Adult -Case Report-

A 57-year-old man presented with recurrent parasagittal anaplastic meningioma of frontoparietal region. The tumor was extensively removed, and the dura was repaired with Gore-Tex surgical membrane. After the operation, subcutaneous cerebrospinal fluid (CSF) collection was observed in the fronto-parietal area and a lumboperitoneal shunt was placed. Four weeks after the shunt procedure, he complained of right scrotal swelling and recurrence of the CSF collection. Radiography revealed the coiled catheter in the scrotum. The catheter was surgically removed through a small incision in the skin of the scrotum under local anesthesia. Lumboperitoneal shunt is a simple and useful procedure to control CSF pressure, but catheter migration has been reported in infants and children. Shunt catheter can migrate into the scrotum even in an adult, as the vaginal process, through which the catheter seemed to have entered the scrotum, is patent in 5% of the adult population. In these cases, direct removal through a small incision is appropriate to remove the catheter.

Effects of Infant Rat Fostering in Artificially Formed Litters on the Development of Brain, Adrenals and Gonads

Morphometric and histochemical properties of neurons in the frontoparietal and parietal lobes and CA1 hippocampal area, thickness of the neocortex, histochemical and morphometric properties of adrenals and gonads, and concentrations of sex hormones were compared in 40-day rats fostered in artificially formed (experimental group) and natural (control) litters. Animals of the experimental group had lower body and brain weight, thickness of the neocortex in the parietal lobe, sizes of nuclei and cytoplasm of layer 2 and layer 5 neurons of the frontoparietal and parietal lobes and in the hippocampus, lower NADPH-dehydrogenase activity in the hippocampus, and lower NADH- dehydrogenase activity in layer 2 neurons of the parietal lobe in comparison with control rats. RNA concentration in neuronal cytoplasm in neocortex and hippocampus was higher in rats from experimental group, than in animals from the control group. Higher estradiol concentration, higher activity of 3β-hydroxysteroiddehydrogenase in thecal cells of ovarian follicles were found in females from experimental group; decreased testicle weight, reduced diameter of seminiferous tubules, reduced activity of 3β-hydroxysteroiddehydrogenase in Leydig's cells, and trend forward lowering of testosterone concentration were found in males from experimental group.

Spontaneous recovery from progressive multifocal leukoencephalopathy in a patient with non-active sarcoidosis

We report the case of a 50-year-old female patient with non-active sarcoidosis and no kind of immunosuppression, admitted to our hospital because of increasing confusion and focal neurological deficits. Initially a tumor, herpes encephalitis, or neurosarcoidosis were suspected, but surprisingly biopsy revealed progressive multifocal leukoencephalopathy, additionally confirmed by JC-positive PCR in cerebrospinal fluid. Cases of sarcoidosis and progressive multifocal leukoencephalopathy have been reported before. This is the first case of a patient with no sign of active sarcoidosis and without immunosuppressive therapy who recovered spontaneously with a follow-up time of nearly 3 years.

Primary malignant melanoma at unusual sites: an institutional experience with review of literature

Apart from the skin and choroid plexus, primary malignant melanoma is rare at the other sites and lacks organized documentation. Here, we have tried to enumerate the primary malignant melanomas at various atypical sites, supported by literature review. Seventeen cases were identified from our records of the past 5 years, which had detailed clinical work-up to exclude a possibility of a metastasis. A clear female predominance with involvement of the lower genitourinary tract was identified. In addition to three cases from the vagina, two cases each from the cervix, ovary and urethra, respectively, such cases were also identified in cerebral cortex (frontal and fronto-parietal area), rectum, nasal cavity, tongue, breast and tonsillar fossa. Although many were amelanotic, no specific histology was noted. In conclusion, malignant melanomas can arise in unconventional areas. Gross tumor appearance and the unavailability of an immunohistochemical panel, may result in their misdiagnosis as primary epithelial malignancies. A possible metastasis should always be ruled out.

The generation, execution and inhibition of motor intention: an ERP study

Objective To investigate neural correlates of the generation,execution and inhibition of motor intention. Methods Behavioral performance and event-related potentials (ERP) of 14 participants were recorded when they performed a two-staged Go-Nogo task. At the stage of intention preparation,three kinds of the what cues were presented separately to the participants : (1) to press a response key by the left or the right hand (the instructed) ,(2) to decide freely which hand will be used (the free) ,(3) to wait for the second cue (the control). At the stage of intention execution,the whether cue suggested the participants execute (Go) or withdraw (Nogo) the previous intention either voluntarily or forcedly. Results The interaction effect between the what and the whether was significant(F(2,26) = 8.262, P=0.002). The forced responses were faster than those of voluntary action under both the instructed condition ((468.52 ±105.87)ms vs (546.67 ±146.33)ms) and the control condition ((536.78 ± 83.28) ms vs (589.75 ± 140.80) ms). No significant difference was found for the free condition((538.71 ± 127. 39) ms vs (561. 44 ± 146. 51) ms). At the stage of intention preparation,significant ERP effects between the instructed intention and the freely intention were revealed in bilateral frontal regions (150～200 ms) , frontoparietal area (300～700 ms)and right temporal area. At the stage of intention execution,ERP effects between voluntary inhibition and voluntary action were observed in left prefrontal area (160～220 ms) ,fro-nto-cento-parietal area and right frontoparietal area. (300～550 ms). Conclusion The motor intention may be generated in the prefrontal area and maintained in the frontoparietal network. The left prefrontal and fronto-centro-parietal areas inhibit intention in the early stage and the right frontoparietal area involves response inhibition lately. Key words: Motor intention; Voluntary inhibition; Event-related potentials

Supratentorial High Convexity Intradural Extramedullary Cavernous Angioma -Case Report-

A 59-year-old man presented with a 2-month history of numbness in the lower left side of the face and upper left extremity. Axial T(1)-weighted magnetic resonance imaging showed a wedge-shaped mass measuring 3 x 2.5 cm in the right frontoparietal high convexity area that was heterogeneously enhanced after administration of gadolinium-diethylenetriaminepenta-acetic acid. Right frontoparietal craniotomy was performed and a bluish soft mass was found under the arachnoid membrane. The mass could be dissected free from the arachnoid membrane and the brain surface. Histological examination revealed the typical findings of cavernous angioma. Cavernous angioma should be considered in the differential diagnosis of supratentorial high convexity intradural extramedullary tumor, especially appearing as a heterogeneously enhanced mass adjacent to the brain parenchyma causing mass effect.

Hemidystonia as an initial manifestation of leptomeningeal metastasis.

A 76-year-old woman gradually developed action dystonia of the left hand and foot. Leptomeningeal metastasis of the right fronto-parietal area associated with gastric adenocarcinoma was found on the brain magnetic resonance imaging (MRI) and positron emission tomography (PET) studies. We discuss the mechanisms involved in the development of secondary hemidystonia and review dystonia associated with cortical lesions.