Decreased cerebral blood flow and prognosis of Alzheimer's disease: A multicenter HMPAO-SPECT study

PURPOSE

To determine the usefulness of brain perfusion SPECT for evaluating the severity and progression of Alzheimer's disease (AD).

METHODS

Eighty-four AD patients were included. At entry, 99mTc-HMPAO-SPECT, the Mini Mental State Examination (MMSE), Mental Function Impairment Scale (MENFIS), and the Raven Colored Progression Matrix (RCPM) were performed for all 84 patients. During the follow-up periods, two individual MMSE evaluations in 34 patients, two MENFIS evaluations in 30 patients, and two RCPM evaluations in 20 patients were performed. Based on the regions of decreased cerebral blood flow demonstrated on 3D-SSP images of SPECT, the cases were classified as type A (no decrease), type B (decreased blood flow in the parietal or temporal lobe), type C (decreased blood flow in the frontal lobe and parietal or temporal lobe), type Pc (decreased blood flow in posterior cingulate gyrus only), and "other types". The types of decreased blood flow, scores on neuropsychological evaluations, and symptom progression were analyzed.

RESULTS

The MENFIS, MMSE, and RCPM scores were poorest in type C patients at entry. The degree of decrease of these scores during the follow-up periods was also greatest in type C. The greatest difference between patients with and without rapid progression in SPECT data of the mild AD patients (MMSE score > or = 24) was in the frontal lobe.

CONCLUSION

Decreased blood flow in the frontal lobe of AD patients is correlated not only with reduced cognitive function at the time of the evaluation but with rapid progression in the subsequent clinical course.

Fibers from the dorsal premotor cortex elicit motor-evoked potential in a cortical dysplasia

OBJECTIVE

To identify the fibers originating from the dorsal premotor cortex (dorsal PMC) that contribute to motor-evoked potentials (MEP), we have applied integrated functional neuronavigation and awake surgery during removal of an epileptic cortical dysplasia located in the right premotor cortex.

METHODS

Chronic subdural electrodes were employed for functional mapping during a routine invasive evaluation for intractable epilepsy. After the fibers originating from the dorsal PMC were plotted into the tractography-integrated functional neuronavigation, subcortical MEPs and clinical symptoms were examined during resection of the epileptogenic dorsal PMC.

RESULTS

During removal of the epileptogenic area, MEPs were elicited by electrical stimulation of the fibers originating from the dorsal PMC, which were separated from the pyramidal tracts from the precentral gyrus. Resection of the dorsal PMC and its fibers caused a transient dysmetric movement of the left toe without motor weakness.

CONCLUSION

Functional corticospinal tract fibers originating from the dorsal PMC can be defined and removed safely under local anesthesia with the aid of integration of functional neuronavigation and subcortical electrical stimulation.

Diffusion tensor fiber tractography of the optic radiation: analysis with 6-, 12-, 40-, and 81-directional motion-probing gradients, a preliminary study

BACKGROUND AND PURPOSE

Knowing the exact location of the optic radiation preoperatively is important for surgery of the temporal lobe. We hypothesized that a greater number of motion-probing gradients (MPGs) would provide better results of diffusion tensor (DT) fiber tractography of the optic radiation. To test this hypothesis, this study evaluated differences in DT fiber tractography of the optic radiation under different MPG settings.

METHODS

DT images were obtained in 12 healthy volunteers (7 men, 5 women) with a mean age of 32 years (range, 22-45 years) by using a 3T MR imaging scanner with single-shot echo-planar imaging with parallel acquisition (reduction factor = 2). MPG was applied in 6, 12, 40, and 81 independent directions. The first region of interest (ROI) was placed in the occipital lobe, and the second ROI was placed in the lateral geniculate body. Fibers penetrating both ROIs were considered as the optic radiation. Anteroposterior distance between the tip of the Meyer loop and the lateral geniculate body on an axial section was defined as a loop index. Numbers of fibers and loop indices in both cerebral hemispheres were evaluated statistically.

RESULTS

The optic radiation was well visualized in full length by DT fiber tractography in 20 of 24 hemispheres (83%). No significant differences were noted in number of fibers and loop indices among different MPG settings.

CONCLUSION

DT fiber tractography can frequently depict almost the entire optic radiation. MPG number does not exert any significant effect on visualization of the optic radiation, and 6-directional MPG is thus sufficient for this purpose.

Heterogeneous epileptogenicity and cortical function within malformations of cortical development: a case report

The authors report a 24-year-old patient with intractable partial epilepsy and massive malformations of cortical development (MCD). Subdural EEG recordings of habitual seizures showed heterogeneous epileptogenicity, and visual evoked potential was recorded within the MCD just adjacent to the most active epileptogenic focus. Resection of the small cortical area presumably with core epileptogenicity, while sparing the cortical functional area, improved seizure outcome without any postoperative functional deficits.

Prefrontal hypofunction in patients with intractable mesial temporal lobe epilepsy

We compared the cognitive functions and interictal cerebral glucose metabolism of 11 patients with mesial temporal lobe epilepsy (MTLE) with frequent seizures to those of 10 patients with MTLE with rare seizures; the groups were matched for age, sex, education, IQ, and focus side. The frequent-seizure group had more set-shifting impairment that correlated with glucose hypometabolism in the prefrontal cortices. Our results suggest that frequent seizures in MTLE are associated with hypofunction of the prefrontal cortex.

[Neuroimaging in mild cognitive impairment]

I summarized the present status of Neuroimaging studies in mild cognitive impairment (MCI). Nation wide multi-center study with regard to single photon emission study had been started 3 year before and it is now going on in a good cooperation of many institute, covering 319 cases. This study was name as J-COSMIC (Japan Cooperative SPECT Study on Assessment of Mild Impairment of Cognitive Function). After one-year follow-up, 30 out of 120 cases were converted to Alzheimer's disease from MCI. Since last year, ADNI (Alzheimer' disease Neuroimaging Initiative) had started in US, very similar to J-COSMIC, but they adopted PET and MRI as the examination tool. The findings based on J-COSMIC is still unclear, but, we can say that the general cognitive evaluation methods such as MMSE is better than WMS-R, which measures the memory function itself with wide variation in each case. Similar to small size previous works, converter from MCI to Alzheimer's disease tended to show hypoperfusion in the parietal and frontal regions. Recent advance in the molecular imaging enabled us to visualize the deposition of amyloid protein in the brain parenchyma. It is still controversial as to application of the early diagnosis of Alzheimer's disease or MCI. S. Minoshima reported the hypometabolism in the early stage of Alzheimer's disease in the posterior cingulate gyrus or precuneus, but it has been still unknown why these areas showed hypoperfusion or hypometabolism in early phase of Alzheimer's disease. We examined the fiber connection of posterior cingulate region with other brain structures using diffusion weighted images. It was very surprising that such kind of small structures had a lot of connections, not only contralateral side, but also, parietal and temporal lobes, as well as anterior cigulate cortex. The function has been still been unclear, but we will be able to disclose their functions in the human brain in the future, which will be helpful for understanding the pathophysiological changes in MCI.

"Target bypass": a method for preoperative targeting of a recipient artery in superficial temporal artery-to-middle cerebral artery anastomoses

OBJECTIVE

To introduce a method for preoperative targeting of a proper recipient artery in superficial temporal artery-to-middle cerebral artery anastomosis.

METHODS

Six operations for superficial temporal artery-to-middle cerebral artery anastomosis in four patients with moyamoya disease or moyamoya-like disease and two operations in two patients with atherosclerotic cerebrovascular occlusive disease accompanied by coronary artery stenosis were performed using our method. Before surgery, a 3-Tesla magnetic resonance imaging study was performed with axial T1-weighted three-dimensional magnetization-prepared rapid acquisition gradient-echo sequences and three-dimensional time-of-flight magnetic resonance angiography. Data on quantitative regional cerebral blood flow were obtained by iodine-123-labeled N-isopropyl-iodoamphetamine single-photon emission computed tomography or positron emission computed tomography. The magnetic resonance angiography and regional cerebral blood flow data sets were registered with the magnetization-prepared rapid acquisition gradient-echo data set by means of the coregistration function of the SPM2 software. We examined the arteries located on or near the cortex where the regional cerebral blood flow had significantly decreased and used the coregistered data set and MRIcro software to select the cortical artery with the largest diameter as the target recipient artery. At the surgery, the data sets were applied to the neuronavigation system and the actual site of the target was confirmed in the operation before scalp incision. The superficial temporal artery was anastomosed with the target through a small craniotomy.

RESULTS

Successful bypass surgery to the target was confirmed in all cases.

CONCLUSION

The "target bypass" method might be effective for cases with moyamoya disease or for cases requiring surgery through a small craniotomy.

Ipsilateral facial sensory and motor responses to basal fronto-temporal cortical stimulation: Evidence suggesting direct activation of cranial nerves

To clarify the generator mechanism of sensory and motor facial responses ipsilateral to electrical stimulation of the inferior fronto-temporal cortex in epilepsy patients. Out of 30 patients who have been evaluated with chronically implanted subdural electrodes for medically intractable partial seizure or brain tumor involving the basal frontal or temporal cortex, 4 patients (age ranging 24-57 years) showed sensory and motor responses in the ipsilateral face to high frequency electrical cortical stimulation of the inferior fronto-temporal cortex. We investigated motor evoked potentials (MEPs) in the facial muscle by single pulse stimulation in 2 out of 4 patients. Three patients showed both sensory symptoms and muscle contraction in the ipsilateral lower face when the orbitofrontal or basal temporal cortex was stimulated with 50 Hz electric current. One patient had only sensory symptoms in the lower face when ipsilateral basal temporal area was stimulated. MEPs at the left orbicularis oris muscle were constantly elicited with the onset latency of 7 ms throughout the stimulus rate of 2-30 Hz in 1 patient out of 2 patients was tested. In another patient, MEP onset latency was 3.0 ms with 11 Hz stimulation. With electrical stimulation of the basal fronto-temporal cortex, the ipsilateral facial twitch might occur through either the direct activation of the facial nerve by the current spread in the middle cranial fossa or through the mechanism similar to blink reflex.

Transient functional suppression and facilitation of Japanese ideogram writing induced by repetitive transcranial magnetic stimulation of posterior inferior temporal cortex

The Japanese writing system is unique in that it is composed of two different orthographies: kanji (morphograms) and kana (syllabograms). The retrieval of the visual orthographic representations of Japanese kanji is crucial to the process of writing in Japanese. We used low-frequency repetitive transcranial magnetic stimulation (rTMS) to clarify the functional relevance of the left and right posterior inferior temporal cortex (PITC) to this process in native Japanese speakers. The experimental paradigms included the mental recall of kanji, kana-to-kanji transcription, semantic judgment, oral reading, and copying of kana and kanji. The first two tasks require the visualization of the kanji image of the word. We applied 0.9 Hz rTMS (600 total pulses) over individually determined left or right PITC to suppress cortical activity and measured subsequent task performance. In the mental recall of kanji and kana-to-kanji transcription, rTMS over the left PITC prolonged reaction times (RTs), whereas rTMS over the right PITC reduced RTs. In the other tasks, which do not involve the mental visualization of kanji, rTMS over the left or right PITC had no effect on performance. These results suggest that the left PITC is crucial for the retrieval of the visual graphic representation of kanji. Furthermore, the right PITC may work to suppress the dominant left PITC in the neural network for kanji writing, which involves visual word recognition.

Corticospinal Tract Localization: Integration of Diffusion-Tensor Tractography at 3-T MR Imaging with Intraoperative White Matter Stimulation Mapping—Preliminary Results

Institutional review board approval and written informed consent were obtained. The purpose of this study was to prospectively validate usefulness of diffusion-tensor (DT) fiber tractography of the corticospinal tract at 3-T magnetic resonance imaging, in combination with the subcortical motor-evoked potential (MEP) technique, as a tool for tractography-guided neurosurgery. DT imaging and corticospinal tractography were performed at 3 T in eight patients (four men, four women; mean age, 41 years; age range, 23-58 years) with intracranial space-occupying lesions. Tractography data were transferred to a neuronavigation system, and tractography-guided neurosurgery was performed. During lesion resection, subcortical MEPs were recorded. Positive MEP response was observed in four patients. No patients developed new motor weakness postoperatively. Complementary use of tractography and MEP may be useful for intraoperative depiction of corticospinal tracts.

The neural basis of social tactics: An fMRI study

One of the most powerful ways of succeeding in complex social interactions is to read the minds of companions and stay a step ahead of them. In order to assess neural responses to reciprocal mind reading in socially strained human relationships, we used a 3-T scanner to perform an event-related functional magnetic resonance imaging study in 16 healthy subjects who participated in the game of Chicken. Statistical parametric mapping showed that the counterpart effect (human minus computer) exclusively activated the medial frontal area corresponding to the anterior paracingulate cortex (PCC) and the supramarginal gyrus neighboring the posterior superior temporal sulcus (STS). Furthermore, when we analyzed the data to evaluate whether the subjects made risky/aggressive or safe/reconciliatory choices, the posterior STS showed that the counterpart had a reliable effect regardless of risky or safe decisions. In contrast, a significant opponent x selection interaction was revealed in the anterior PCC. Based on our findings, it could be inferred that the posterior STS and the anterior PCC play differential roles in mentalizing; the former serves as a general mechanism for mentalizing, while the latter is exclusively involved in socially risky decisions.

Song and speech: Brain regions involved with perception and covert production

This 3-T fMRI study investigates brain regions similarly and differentially involved with listening and covert production of singing relative to speech. Given the greater use of auditory-motor self-monitoring and imagery with respect to consonance in singing, brain regions involved with these processes are predicted to be differentially active for singing more than for speech. The stimuli consisted of six Japanese songs. A block design was employed in which the tasks for the subject were to listen passively to singing of the song lyrics, passively listen to speaking of the song lyrics, covertly sing the song lyrics visually presented, covertly speak the song lyrics visually presented, and to rest. The conjunction of passive listening and covert production tasks used in this study allow for general neural processes underlying both perception and production to be discerned that are not exclusively a result of stimulus induced auditory processing nor to low level articulatory motor control. Brain regions involved with both perception and production for singing as well as speech were found to include the left planum temporale/superior temporal parietal region, as well as left and right premotor cortex, lateral aspect of the VI lobule of posterior cerebellum, anterior superior temporal gyrus, and planum polare. Greater activity for the singing over the speech condition for both the listening and covert production tasks was found in the right planum temporale. Greater activity in brain regions involved with consonance, orbitofrontal cortex (listening task), subcallosal cingulate (covert production task) were also present for singing over speech. The results are consistent with the PT mediating representational transformation across auditory and motor domains in response to consonance for singing over that of speech. Hemispheric laterality was assessed by paired t tests between active voxels in the contrast of interest relative to the left-right flipped contrast of interest calculated from images normalized to the left-right reflected template. Consistent with some hypotheses regarding hemispheric specialization, a pattern of differential laterality for speech over singing (both covert production and listening tasks) occurs in the left temporal lobe, whereas, singing over speech (listening task only) occurs in right temporal lobe.

Epileptic polyopia with right temporal lobe epilepsy as studied by FDG-PET and MRI: a case report

Polyopia is one of rare, visual hallucinations. A 61-year-old man suffered from daily episodes of polyopia and generalized convulsions, and he was diagnosed as right temporal lobe epilepsy. MRI revealed right amygdalar swelling. FDG-PET showed hypometabolism in the right anterior temporal and the mesial occipital areas. Polyopia is thought to be caused by dysfunction of updating process of visual information in the visual association cortices. It was most likely that, in this patient, both mesial temporal and ipsilateral occipital areas were responsible for manifesting epileptic polyopia, as ictal onset zone and symptomatogenic zone, respectively.

Language Control in the Bilingual Brain

How does the bilingual brain distinguish and control which language is in use? Previous functional imaging experiments have not been able to answer this question because proficient bilinguals activate the same brain regions irrespective of the language being tested. Here, we reveal that neuronal responses within the left caudate are sensitive to changes in the language or the meaning of words. By demonstrating this effect in populations of German-English and Japanese-English bilinguals, we suggest that the left caudate plays a universal role in monitoring and controlling the language in use.

Somatosensory evoked magnetic fields to air-puff stimulation on the soft palate

Impairment of sensory input to the soft palate has been reported in patients with obstructive sleep apnea syndrome. To investigate the reaction in the central nervous system related to soft palate perception, we measured the somatosensory evoked magnetic fields following air-puff stimulation in seven healthy volunteers by using a helmet-shaped 122-channel neuromagnetometer. The air-puffs were produced using compressed nitrogen and directed to the middle of the soft palate with an intraoral device. To evaluate the laterality of responses we used another appliance in which the air-puffs were directed to the middle and right side of the soft palate. In all the subjects, responses were identified symmetrically in the bilateral parietotemporal regions with a mean latency of about 130 ms from the soft palate stimulation. Prior to this peak, no distinct early responses were observed. There was no significant difference in the responses between the middle and right side stimulation. Corresponding equivalent current dipoles were estimated around the Sylvian fissures. These results suggested that the responses were derived from the second somatosensory areas. In conclusion, we could record long-latency responses to air-puff stimulation of the soft palate in the bilateral second somatosensory areas.