Left Peduncle Research Articles

Case Report: Bilateral optic disc swelling in a patient with tuberculoma

BACKGROUND: In children, tuberculosis of the central nervous system most usually manifests as tubercular meningitis, hydrocephalus post-tubercular meningitis, and, in rare cases, space-occupying lesions known as tuberculoma. We address the diagnostic difficulty in an adult patient with mainly ocular symptoms who was diagnosed with tuberculoma. A 19-year-old young man came with painless bilateral blurring of vision. Bilateral optic disc swelling and bilateral sixth cranial nerve palsy were present. METHODS: Brain imaging revealed ring-enhancing lesions in the cerebellar vermis, left cerebellar hemisphere and left middle cerebral peduncle with surrounding extensive perilesional edema causing effacement of fourth ventricle leading to obstructive hydrocephalus suggestive of tuberculoma. RESULTS: He had a high erythrocyte sedimentation rate and a positive Mantoux test. His Quantiferon-TB Gold test result was positive. The examination of cerebrospinal fluid suggested a high opening pressure. Following anti-tubercular medication along with systemic steroids, his vision improved due to decreased optic disc swelling. CONCLUSION: We wish to highlight that visual loss and grave consequences of tuberculoma can be averted with early recognition and treatment.

White matter changes in young and middle-aged males with chronic prostatitis/chronic pelvic pain syndrome: Tract-based spatial statistics analysis.

The supraspinal mechanism plays a key role in developing and maintaining chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). However, it is not clear how white matter changes in young and middle-aged males with CP/CPPS. In this cross-sectional study, 23 CP/CPPS patients and 22 healthy controls (HCs) were recruited. Tract-based spatial statistics was applied to investigate the differences in diffusion tensor imaging metrics, including fractional anisotropy (FA), mean diffusion (MD), radial diffusion (RD) and axial diffusion (AD), between CP/CPPS patients and HCs. The study also examined the association between white matter alterations and clinical variables in patients using correlation analysis. Compared with HCs, patients showed decreased FA, MD, RD and AD in the body and genu of the corpus callosum and right anterior corona radiata. In addition, they showed increased FA along with decreased MD, RD and AD in the left posterior limb of the internal capsule (PLIC-L), left external capsule and left cerebral peduncle. The FA of PLIC-L was negatively correlated with disease duration (r = -.54, corrected p =.017), while MD and RD were positively correlated (r = .45, corrected p =.042; r = .57, corrected p =.017). These results suggest that CP/CPPS is associated with extensive changes in white matter tracts, which are involved in pain processing. In particular, the FA, MD and RD values in the PLIC-L were correlated with the disease duration, indicating that the long-term course of CP/CPPS may have effects on the white matter microstructure of the pain perception pathways.

HSV-2 Retinitis and Encephalitis Masquerading as Giant Cell Arteritis and Acute Ischemic Stroke of the Midbrain (P12-10.002)

<h3>Objective:</h3> To describe a unique case of stroke mimicry. <h3>Background:</h3> Non-vascular causes of acute neurological symptoms may clinically and radiographically mimic ischemic strokes. In the brainstem, such considerations are generally restricted to neoplastic, demyelinating, or infectious etiologies. HSV-2 may very rarely cause isolated mesencephalitis. <h3>Design/Methods:</h3> We describe a patient who presented with headache, arthralgias, and visual dysfunction who was initially diagnosed with giant cell arteritis (GCA) but was eventually found to have HSV-2 infection. <h3>Results:</h3> A 75-year-old man with past medical history notable for atrial fibrillation (on apixaban), hypertension, hyperlipidemia, and rheumatoid arthritis (on adalimumab) presented for evaluation of gait instability. Four weeks prior to presentation, he developed bitemporal headaches without visual symptoms and arthralgias. His rheumatologist checked an ESR (40) and ordered a temporal artery biopsy. He presented the day his apixaban was held prior to biopsy (1 week prior to this presentation) with right eye inferior visual field loss. Fundoscopy revealed disc edema felt consistent with anterior ischemic optic neuropathy. He was treated with pulse-dose steroids out of concern for GCA and underwent bilateral temporal artery biopsy before being discharged home on an oral steroid taper and resumed anticoagulation. CT, CTA, and MRI were reportedly normal and the biopsies were ultimately negative. He then presented this admission with gait instability and MRI exhibited a diffusion restricting lesion with T2-FLAIR hyperintensity without hemorrhage in the left cerebral peduncle. His visual symptoms progressed and he underwent right eye anterior chamber paracentesis with fluid resulting PCR positive for HSV-2. Subsequent CSF sampling also revealed lymphocytic pleocytosis and HSV-2 positivity. Despite maximal medical therapy, he lost vision in both eyes over a matter of weeks before developing Charles-Bonnet syndrome. <h3>Conclusions:</h3> HSV-2 encephalitis may cause mesencephalic, non-hemorrhagic, restricting lesions mimicking acute ischemic stroke. HSV may also cause a necrotizing retinitis, initially mimicking ischemic, even arteritic, optic neuropathy. <b>Disclosure:</b> Dr. Sutherland has received personal compensation in the range of $0-$499 for serving as a Consultant for McGraw-Hill. Dr. Gummerson has nothing to disclose. Dr. De Havenon has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Integra. Dr. De Havenon has stock in Certus. The institution of Dr. De Havenon has received research support from NIH/NINDS. The institution of Dr. De Havenon has received research support from Regeneron Pharmaceuticals. The institution of Dr. De Havenon has received research support from AMAG Pharmaceuticals. The institution of Dr. De Havenon has received research support from AMGEN. Dr. De Havenon has received publishing royalties from a publication relating to health care.

Iron Deficiency Anemia and Ischemic Stroke in Premenopausal Women (P14-5.022)

<h3>Objective:</h3> We describe three young women with iron deficiency anemia who developed ischemic strokes in the absence of typical risk factors. <h3>Background:</h3> Ischemic stroke is the third leading cause of death in women. Women have unique risk factors for ischemic stroke. Iron deficiency anemia disproportionately affects premenopausal women and has previously been identified to be associated with ischemic stroke. <h3>Design/Methods:</h3> N/A <h3>Results:</h3> A 39-year old woman with hypertension and menorrhagia presented with left leg weakness and dizziness. Labs revealed a hemoglobin of 5.9g/dL, a unremarkable hypercoagulable work up, transesophageal echo, urine toxicology, rheumatological evaluation, and MRA brain vessel wall imaging. An ultrasound of her uterus revealed a pelvic fibroid measuring 6.5cm and MRI brain revealed a small right anterior cerebral artery territory infarction. A 46-year-old woman with chronic iron deficiency anemia with a hemoglobin of 6.8g/dL who presented with left mild sided weakness and was found to have a right MCA M3 occlusion by CT angiography of the head. She received intravenous tenecteplase and underwent decompressive craniectomy for a right temporal infarct associated with cerebral edema seen on MRI brain. Investigations revealed a normal hemoglobin electrophoresis, urine toxicology, hypercoagulable evaluation, rheumatological evaluation and transesophageal echo. A 43 year old woman presented with diplopia secondary to a vertical gaze palsy. MRI brain revealed an infarct in the left thalamus, cerebral peduncle, and midbrain. Cerebral angiography, transesophageal echocardiogram, urine toxicology, rheumatological evaluation, and hypercoagulable work up were unremarkable. Hemoglobin was 7.2g/dL on presentation and an EGD revealed an antral and duodenal ulcer. All three patients received packed RBC transfusions, iron replacement therapy and discontinuation of aspirin until hemoglobin stabilized. <h3>Conclusions:</h3> Iron deficiency anemia may be an important yet under-recognized risk factor for acute ischemic stroke and should be treated aggressively in premenopausal women. Further studies are warranted. <b>Disclosure:</b> Dr. Imam has nothing to disclose. Dr. Salahuddin has nothing to disclose.

Concomitant brain abscess and spinal cord abscess in an immunocompetent teenage male: illustrative case.

Multiple bilateral brain abscesses occur rarely in immunocompetent patients. Hematogenous spread to the central nervous system (CNS) allows suppuration and abscess formation in the privileged immune environment of the CNS; hematogenous spread to the spinal cord is extremely rare and the combination of multifocal brain abscesses and intramedullary abscesses has not been reported. This report presents a rare presentation and diagrams a treatment algorithm involving iterative minimal access surgeries and prolonged medical management. The authors present a case of an 18-year-old male with numerous multifocal and bilateral intraparenchymal abscesses and a medically resistant C5 intramedullary spinal cord abscess. The symptomatic patient had a left oculomotor palsy and left hemiparesis, ultimately undergoing ultrasound-guided aspiration of abscesses in the left frontal and left cerebral peduncle. Following transient motor improvement, he evolved tetraparesis prompting spinal cord imaging and emergent ultrasound-guided needle aspiration of an occult C5 intramedullary spinal cord abscess. The patient received appropriate medical therapy, completed inpatient rehabilitation, and made a full recovery. Needle- and ultrasound-guided catheter drainage of CNS abscesses should be considered for symptomatic lesions. Following the neurological examination closely is extremely important; if the expected neurological improvement is delayed or regresses, then expanded imaging is warranted.

Effects of exercise types on white matter microstructure in late midlife adults: Preliminary results from a diffusion tensor imaging study.

Higher aerobic fitness during late midlife is associated with higher white matter (WM) microstructure. Compared with individuals engaged in irregular exercise, those who engage in regular aerobic exercise show higher fractional anisotropy (FA), a diffusion tenor imaging (DTI) measure that provides an index of WM microstructural integrity. However, whether other types of exercise, such as Tai Chi, can also facilitate WM changes in adults during late midlife remains unknown. The present study compares two types of exercise, Tai Chi and walking, with a sedentary control group, in order to examine the effects of exercise on WM microstructure and determine the regional specificity of WM differences. Thirty-six healthy adults between the ages of 55 and 65 years participated in the study. Based on the participants' exercise habits, they were allocated into three groups: Tai Chi, walking, or sedentary control. All participants were required to complete physical fitness measurements and completed magnetic reasoning imaging (MRI) scans. Our results revealed that the Tai Chi group exhibited a higher FA value in the left cerebral peduncle, compared to the sedentary control group. We also observed that both the Tai Chi and walking groups exhibited higher FA values in the right uncinate fasciculus and the left external capsule, in comparison to the sedentary control group. Increased FA values in these regions was positively correlated with higher levels of physical fitness measurements (i.e., peak oxygen uptake [VO2peak], muscular endurance/number of push-up, agility, power). These findings collectively suggest that regular exercise is associated with improved WM microstructural integrity, regardless of the exercise type, which could guide the development and application of future prevention and intervention strategies designed to address age-related cognitive impairments during late midlife.

A case of Kernohan-Woltman notch phenomenon caused by an epidural hematoma: the diagnostic and prognostic value of PET/CT imaging

BackgroundKernohan-Woltman notch phenomenon (KWNP) classically occurs when a lesion causes compression of the contralateral cerebral peduncle against the tentorium, resulting in ipsilateral hemiparesis. It has been studied clinically, radiologically and electrophysiologically which all confirmed to cause false localizing motor signs. Here, we demonstrate the potential use of fluorine-18 fluorodeoxyglucose (18 F-FDG) positron emission tomography/computed tomography (PET/CT) to identify KWNP caused by an epidural hematoma.Case presentationA 29-year-old male patient post right-sided traumatic brain injury presenting with persistent ipsilateral hemiparesis. Patient underwent decompressive craniotomy and intracranial hematoma evacuation. Brain magnetic resonance imaging in the postoperative period showed a subtle lesion in the left cerebral peduncle. PET/CT was performed to exclude early brain tumor and explain his ipsilateral hemiparesis. PET/CT imaging demonstrated a focal region of intense 18 F-FDG uptake in the left cerebral peduncle. Throughout the treatment in outpatient neurorehabilitation unit, the patient exhibited a gradual recovery of his right hemiparesis.ConclusionIn our case report, for the first time, PET/CT offered microstructural and functional confirmation of KWNP. Moreover, our case suggests that 18 F-FDG PET/CT may serve as an important reference for the probability of functional recovery.

Central nervous system infection with Seoul Orthohantavirus in a child after hematopoietic stem cell transplantation: a case report

BackgroundPatients with allogeneic hematopoietic stem cell transplantation (allo-HSCT) are prone to complicate viral infection. Central nervous system (CNS) involvement caused by the viruses is rare but with poor prognosis. Hantavirus, which usually cause hemorrhagic fever with renal syndrome (HFRS), and none case has been reported about these infection in allo-HSCT patients.Case presentationIn August 2021, a 13-year-old male child developed intermittent fever and refractory hypotension after allo-HSCT. Magnetic resonance imaging of the head revealed abnormal signal foci in the left midbrain cerebral peduncle and bilateral thalamus. His family reported traces of mouse activity in the patient’s home kitchen. HFRS was suspected, but with no significant kidney damage. The specific immunoglobulin (Ig) G and M of hantavirus were negative. The metagenomic next-generation sequencing (mNGS) detected Seoul Orthohantavirus (SEOV) sequences directly in cerebrospinal fluid and blood.ConclusionsAllo-HSCT patients are a high-risk group for infection. Usually the causative agent of infection is difficult to determine, and sometimes the site of infection is concealed. This report highlights the importance of suspecting hantavirus infection in allo-HSCT patients with CNS symptoms despite the absence of renal syndromes. The mNGS is a powerful tool for detecting pathogens. CNS infection with Seoul orthohantavirus in transplant patients is rare but possible as demonstrated in this case. To the best of our knowledge, this is the first reported case employing mNGS to diagnose SEOV caused CNS infection in an allo-HSCT patient.

Tumor growth, angiogenesis, and invasion as clinical hallmarks of glioblastoma: A case report

The clinical hallmarks of tumor growth, angiogenesis, and invasion were identified in a patient with isocitrate dehydrogenase-1 wild-type glioblastoma at initial diagnosis and management issues were examined. The head magnetic resonance imaging (MRI) showed multiple solid and cystic contrast enhancements in the rostral portion of the tumor located within the left motor gyrus and the adjacent brain. Extensive tumor invasion was noted along the left corticospinal tract extending into the cerebral peduncle and pons. After an open craniotomy for tissue biopsy, the patient underwent external beam radiotherapy and concomitant temozolomide, and his motor deficit was stabilized with concurrent bevacizumab infusion while dexamethasone was weaned off. After two cycles of adjuvant temozolomide, the patient experienced worsening motor deficit in the right hand. A repeat gadolinium-enhanced head MRI revealed increased fluid-attenuated inversion recovery hyperintensity in the left cerebral peduncle indicating tumor progression. This case illustrates the extensive invasion from a glioblastoma that cannot be adequately quantified or effectively treated. A wider margin of radiation may be needed to cover microscopic and infiltrative tumor cells. The early use of bevacizumab can also reverse neurological deficits and obviate the long-term use of dexamethasone and insulin in this patient. This study was approved by the Institutional Review Board at Dana Farber Cancer Institute #12-519 onMay 5, 2020.

Hemiparkinsonism Secondary to Giant Aneurysm.

An 81-year-old woman presented with progressive right levodopa-nonresponsive hemiparkinsonism for 6 months. Brain CT scan and MRI (Figure 1) showed a giant supraclinoid unruptured aneurysm of the left internal carotid artery, leading to severe left basal ganglia displacement and left cerebral peduncle compression. The patient underwent ioflupane SPECT (Figure 2) that showed decreased tracer binding exclusively in the left putamina and left caudate nuclei. The preserved presynaptic dopaminergic function of right basal nuclei ruled out an unmasked latent Parkinson disease.

840 Obstructive to Central: A switch in sleep apnea type after arteriovenous malformation rupture

Abstract Introduction Sleep apnea and stroke have long been shown to be linked, with sleep apnea increasing the risk for stroke and stroke leading to sleep apnea. When the latter occurs, it can present as central sleep apnea (CSA), often in the form of Cheyne-Stokes breathing (CSB), and has been shown to resolve over time. We present a patient with persistent CSA after severe hemorrhagic stroke secondary to rupture of a temporal/thalamic arteriovenous malformation (AVM). Report of case(s) A 33-year-old man with a history of obstructive sleep apnea (OSA) presented to our clinic for re-evaluation of his disease. He was diagnosed with OSA in 2006 at which time he was 270 pounds with a body mass index (BMI) of 36.7, thus the OSA was thought to be secondary to obesity. When he presented to our clinic 10 years later, he had lost approximately 80 pounds after suffering multiple strokes. In 2014, he had a left temporal lobe hemorrhage due to rupture of a left temporal/thalamic AVM and required decompressive hemicraniectomy. In 2015, he had a re-bleed of this AVM, with new hemorrhage extending inferiorly into the left cerebral peduncle and pons, and superiorly into the left parietal periventricular white matter anteriorly along the optic tract. Ultimately, he was treated with stereotactic radiotherapy to the AVM nidus with no residual AVM. However, he has chronic encephalomalacia of the left basal ganglia, thalamus, temporal, parietal, and occipital lobes with extension into the left cerebral peduncle and changes consistent with radiation necrosis. His residual symptoms are aphasia and right-sided hemiplegia and although his snoring resolved with weight loss, his mother noticed pauses in his breathing overnight. A repeat sleep study done in 2016 showed 27 central apneas and 0 obstructive apneas with an AHI of 5.4 events/hour. He was subsequently studied on ASV with residual AHI of 0.4 events/hour. Conclusion Although patients with OSA may be at higher risk for stroke, it is important to re-evaluate their sleep apnea after such an event to ensure appropriate diagnosis and treatment going forward. Support (if any):

Dyke-Davidoff-Masson syndrome.

We are presenting a case of 15-year old male patient presented with weakness of right upper and lower limbs, difficulty lifting objects with the right hand. He was born full term to non- consanguineous parents with no significant antenatal or perinatal history. On examination there was hemi-atrophy of the right side of the body with simultaneous involuntary movements of contralateral hand accompanying voluntary movement of the ipsilateral side. Neurological examination reveals right side spastic hemiparesis with upper limb more affected than lower limb. Tendon reflexes were brisk on affected side with extensor plantar response. Mini mental status examination score was 26/30 suggestive of mild cognitive impairment. Other systemic examinations were within normal limits. Plain and contrast MRI of brain findings reveal left cerebral hemi-atrophy with thinning of the ipsilateral grey matter cortex, reduced volume of the underlying white matter, enlargement of the left lateral ventricle and reduced size of ipsilateral left cerebral peduncle is noted. Along with slight compensatory thickening of the ipsilateral skull vault is seen. Findings confirm diagnosis of Dyke-Davidoff-Masson Syndrome. He was under medical management along with physiotherapy rehabilitation focussing majorly on hand rehabilitation.

Diffusion tensor imaging (tractography) in elderly people with mixed dementia and mild Alzheimer's disease

AbstractBackgroundCerebral tractography is a Magnetic Resonance Imaging technique that allows you to visualize the white matter fascicles that connect different parts of the brain. It is based on the diffusion of water in biological tissues, through which fiber tracts are evaluated in a three‐dimensional space, which allows to obtain the Anisotropy Fraction (FA) and Medium Diffusivity (DM). Tractography allows correlating the integrity of these pathways with cognitive function. The objective of our study was to identify anatomical regions with alterations in AF in mixed dementia compared to AD.Method16 patients were included; 8 with Mixed Dementia (DMix) and 8 with Alzheimer's Disease (AD). Mean, standard deviations and frequencies were used, as well as Chi‐square and Mann‐Whitney tests. A linear regression model was used to determine the association between Tractography and performance in cognitive domains, adjusted for age and educational level.ResultsThe mean age of the participants was 85 ± 7.9 years (p ≤.57), 69% were women (p ≤.10) and the educational level was 11 ± 6.0 years (p ≤.87). Participants with AD had a worse cognitive performance (NEUROPSI: 68.5 ± 11.6 points, p ≤.02) compared to the DMix group. When analyzing by cognitive domains, patients in the DMix group had a worse performance in phonological verbal fluency (7.0 ± 3.5 words, p ≤.05). Regarding neuroimaging, significant differences were observed in participants with DMix in the Anisotropy Fraction (AF) in the following tracts: right cerebral peduncle (0.5557 ± 0.0121, p ≤.05), left cerebral peduncle (0.5476 ± 0.0121, p ≤0.01), right external capsule (0.3346 ± 0.0163, p ≤0.01) and left cingulate gyrus (0.3756 ± 0.0241, p ≤0.05) and mean diffusivity in the right thalamic posterior radiation (0.0010 ± 0.0000, p ≤ 0.03) and left external capsule (0.0012 ± 0.0001, p ≤0.03).ConclusionTractography allows quantifying and differentiating anatomical regions with myelin damage in mixed dementia compared to AD.

A Puzzling Exam: Kernohan’s Notch Reimaged

•We provide a visual image of the consequeces of massive brainstem shift with oculomotor and peduncle injury.•Acute space occupying lesions may cause ipsilateral hemiparesis – and can be a false localizing sign. Conventional teaching on the neurologic examination suggests findings can be attributed to specific regions – which improves timely diagnosis and treatment, particularly in life threatening situations. Rarely, puzzling patient presentations can wrongly lead to false localization. A 36-year-old man was found comatose. Head CT demonstrated an acute right convexity subdural hematoma, causing a nearly 2 cm midline shift. Initial neurologic examination was confounded by paralytic agents; however, there was a dilated-light fixed right pupil. The patient was taken for a right hemicraniectomy and hematoma evacuation (Fig. 1). Post-operative examination demonstrated right-sided oculomotor palsy and hemiplegia with preserved left-sided strength—consistent with a false localizing sign. An MRI on POD#1 revealed abnormal T2-signal hyperintensity involving the left anterolateral midbrain and cerebral peduncle, indicative of compression of the contralateral crus cerebri against the contralateral tentorial incisura (“notch”). The descending corticospinal tracts travel from the motor cortex through the ipsilateral crus cerebri into the inferior brainstem where they decussate-transmitting motor stimuli to the contralateral hemibody. Correspondingly, right-sided lesions above the decussation produce left-sided deficits. In the present case, the expected deficits would have been in the left hemibody. However, in rare circumstances involving a significant midline shift the contralateral peduncle is injured via compression at the tentorium. The oculomotor at the same side of the hematoma is as expected and either caused by strech of the nerve or direct compression of the uncus. This false localizing sign has been honored by the eponym "Kernohans Notch"..[[1]Kernohan J.W. Woltman H.W. Incisura of the crus due to contralateral brain tumor.Arch NeurPsych. 1929; 21: 274-287https://doi.org/10.1001/archneurpsyc.1929.02210200030004Crossref Scopus (117) Google Scholar] More deserving of the distinction is Groeneveld [[2]Dammers R Volovci V and Kompanje EJOThe History of the Kernohan Notch Revisited.Neurosurgery. 2016; 78: 581-584https://doi.org/10.1227/NEU.0000000000001097Crossref PubMed Scopus (0) Google Scholar] and Schaltenbrand who explained the injury as a knife-like stab (“Messerähnlichen Wirkung”) from the tentorium and possibly petrosal bone. There is a fascination with the Kernohan's notch phenomenon as evidenced by an ongoing flurry of case reports in the literature. Our patient clearly visualizes what has previously only been described in text and provides better proof of its existance. Picture Quiz: A 36 year-old male found down is noted on neurologic examination to have right hemiplegia and right oculomotor nerve palsy, with intact left upper and lower extremity function. Based on the exam, what is the most likely level of the lesion? A. Left motor cortex B. Right basal ganglia C. Left cerebral peduncle D. Right upper medulla Answer on page 336. LPC, AP, RCP, PCR, JLF, and EFW all provided substantial direct medical or surgical care pertaining to the diagnosis and treatment of the patient; LPC, AP, and CSG gathered the data and wrote manuscript/created the figure, PJR obtained formal patient consent and edited the manuscript, JLF and EFW supervised the project and made final manuscript editorial edits and approvals. None. The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. A Puzzling Exam: Kernohan’s Notch ReimagedJournal of Clinical NeuroscienceVol. 80PreviewThe Answer is: C. Left cerebral peduncle. Full-Text PDF

Aberrancies of Brain Network Structures in Patients with Anosmia

Patients with anosmia exhibit structural and functional brain abnormalities. The present study explored changes in brain white matter (WM) in non-neurodegenerative anosmia using diffusion-tensor-based network analysis. Twenty patients with anosmia and sixteen healthy controls were recruited in the cross-sectional, case-control study. Participants underwent olfactory tests (orthonasal and retronasal), neuropsychological assessment (cognitive function and depressive symptoms) and diffusion tensor imaging measurement. Tract-Based Spatial Statistics, graph theoretical analysis and Network-Based Statistics were used to explore the white matter. There was no significant difference in fractional anisotropy (FA) between patients and controls. In global network topological properties comparisons, patients exhibited higher γ and λ levels than controls, and both groups satisfied the criteria of small-world (σ > 1). In local network topological properties, patients had reduced betweenness, degree and efficiency (global and local), as well as increased shortest path length and cluster coefficient in olfactory-related brain areas (anterior cingulum, lenticular nucleus, putamen, hippocampus, amygdala, caudate nucleus, orbito-frontal gyrus). Olfactory threshold scores and the retronasal score were negatively correlated with γ and λ, and the retronasal score was positively correlated with FA values in certain WM tracts, i.e. middle cerebellar peduncle, right inferior cerebellar peduncle, left inferior cerebellar peduncle, right cerebral peduncle, left cerebral peduncle, left cingulum (cingulate gyrus), right cingulum (hippocampus), superior fronto-occipital fasciculus, and, left tapetum. Patients with anosmia demonstrated relevant WM network dysfunction though their structural integrity remained intact. Their retronasal olfaction deficits revealed to be more strongly associated with WM alterations compared with orthonasal olfactory scores.

The association between physical fitness parameters and white matter microstructure in older adults: A diffusion tensor imaging study.

The present study was designed to examine whether different measures of physical fitness are differentially associated with white matter (WM) microstructure in older adults. Fifty-six healthy adults (mean age: 59.14years) completed a standardized evaluation of physical fitness measurements (e.g., VO2peak , push-ups, abdominal sit-ups, sit-and-reach, t test, and vertical jump). Fractional anisotropy (FA), an index of WM microstructure, was assessed using diffusion tensor imaging. The findings indicated that the cardiorespiratory fitness was positively associated with FA in the right cingulum hippocampus and the left cerebral peduncle. However, other physical fitness metrics were not significantly associated with FA in any region. These results suggest that cardiorespiratory fitness, but not other metrics of fitness, might be sensitive to WM microstructure.

White matter microstructural organizations in patients with severe treatment-resistant schizophrenia: A diffusion tensor imaging study

Previous diffusion tensor imaging (DTI) studies have reported white matter alterations in patients with schizophrenia. Notably, one third of this population does not respond to first-line antipsychotics and is thus referred to as treatment-resistant schizophrenia (TRS). Despite potentially distinct neural bases between TRS and non-TRS, few studies have compared white matter integrity between these groups. In order to reflect clinical picture of TRS, we enrolled TRS patients who had severe symptoms. According to the consensus criteria for TRS. TRS was defined by severe positive symptomatology despite optimal antipsychotic treatment. Fractional anisotropy (FA), an index of white matter integrity, was examined by DTI and analyzed with tract-based spatial statistics in 24 TRS patients (mean PANSS = 108.9), 28 non-TRS patients (mean PANSS = 50.0), and 27 healthy controls (HCs) for group comparison. Additionally, correlation analyses were conducted between FA values and symptomatology. The TRS group had lower FA values in multiple tracts (cerebral peduncle, corona radiata, corpus callosum, external and internal capsules, posterior thalamic radiation, sagittal stratum, superior longitudinal fasciculus, tapetum, and uncinate fasciculus) compared to the HC group as well as the non-TRS group (p < .05; family-wise error-corrected), while no differences were found between the non-TRS and HC groups. In the TRS group, FA values in most of the tracts (other than the left anterior limb of internal capsule, left cerebral peduncle, and right uncinate fasciculus) were negatively correlated with the Positive and Negative Syndrome Scale total scores, and negative and general symptom scores. No such relationships were found in the non-TRS group. The identified white matter integrity deficits may reflect the pathophysiology of TRS.

Paramedian contralateral supracerebellar infratentorial approach to thalamic cavernous malformation.

Cavernous malformations (CVMs) located in the thalamus are uncommon. However, they pose difficulties for resection because of their close proximity to eloquent areas of the brain and vascular structures, and all surgical corridors to access them are narrow. In this video, we report the case of a 19-year-old woman who presented with a long-standing history of right hemiparesis with recent deterioration. MRI revealed a large CVM located in the left thalamus, with signs of recent hemorrhage extending to the left cerebral peduncle. Resection was achieved with a paramedian contralateral supracerebellar infratentorial approach in a semisitting position, with an uneventful postoperative course.The video can be found here: https://youtu.be/Arvu52FkHOE.

Design and performance evaluation of 3D printed writing and typing assistive devices: A pragmatic single participant study

INTRODUCTION: 3D Printing can be used to make prosthetic and assistive devices for the physically disabled with the advantages of being affordable and bespoke. A physically challenged test participant was selected who required assistive devices for writing and typing. The participant had a pilocyti c astrocytoma in the left peduncle in 2013, which was successfully removed. However, some right arm motor function was lost decreasing writing and typing ability, and forcing adaptation of the left arm. Thus, 3D printed devices were developed to assist the right arm with writing and typing. METHOD: The study employed an Alternative Treatment Design, in which writing and typing tests occurred every day for the first three days and then the fifth and seventh days. Two devices were made for writing and two for typing. RESULTS: The writing device that consisted of a 2-ring connected design (one finger fits into one ring and the writing utensil into the other) was 15% faster than without any aid on the right hand. Its use also showed the smallest average deviation from a template, 1.8 mm (0.07 in), offering the neatest handwriting quality for the right hand. Regarding typing, the design consisting of a ring and pointer was found to be 54% faster than using no assistive device on the right hand (when typing with right hand alone) and 30% faster than using no assistive device (when using both hands to type). DISCUSSION: The study can assist others who intend to produce assistive devices for writing and typing by not only providing ideas for bespoke designs but also the ways in which these assistive devices can be assessed.

Long Term Follow up of Cerebellar Ataxia CA) and MRI Lesions Which Responded to Copper (Cu) Supplementation (P12-055-19)

ObjectivesCu deficiency (CuD) produces anemia and leukopenia. CuD neurologic dysfunction can also occur. We follow a patient with CuD with CA and MRI lesions that responded to Cu replacement. MethodsA 64-year-old male with progressive ataxia and neuropathy was found to have a significant CuD (copper level 38 mmol/L, normal range 70–175) 7 years ago. The etiology of CuD was unknown. There was no previous gastric surgery, malabsorption, ingestion of zinc containing products or medications associated with Cu loss.He had an ataxic gait with a steppage component. Muscle stretch reflexes were brisk at the knees and absent at the ankles. He had length dependent loss to all modalities. Other etiologies for CA were not found. The blood smear showed anisocytes and poikilocytes, but anemia and leukopenia were absent. He became wheelchair bound after several weeks.Brain MRI without contrast revealed non-enhancing symmetric T2 signal prolongation of the medial cerebellar white matter extending into left middle cerebral peduncle. Neuroconductive studies showed moderate-to-severe axonal sensorimotor polyneuropathy. ResultsCu supplementation with using 5 mg cupric oxide daily raised serum Cu to 97 mmol/L. Symptoms improved after 1 month. Brain MRI 3 months later showed no cerebellar lesions with serum Cu of 123 mmol/L. At this point he was able to walk with a cane. His gait disturbance further improved to the extent that he was able to walk without assistance or support. His follow up Cu levels remain in the normal range (last value = 128 mmol/L). ConclusionsCu is a component of the neurologic metalloenzymes cytochrome-c oxidase (CcO), Cu-zinc superoxide dismutase, tyrosinase, dopamine β-hydroxylase, peptidylglycine α-amidating monooxygenase and ceruloplasmin. Cu and iron pass electrons through CcO to oxygen, forming water. CuD impacts the electron transport chain, impairing ATP production which injures susceptible tissues.This case demonstrates the reversibility of neurologic dysfunction and MRI lesions by means of correcting CuD. Our 7-year follow up period confirms the validity of the pathogenesis and management. Further study is needed to identify the specific roles of Cu metabolism in such cases and the individual factors allowing for the dramatic response we observed. Funding Sourcesnone.