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Background: Parkinson's disease (PD)-related pain or PD pain is a frequent non-motor symptom and is treated with pharmacotherapy and non-pharmacologic therapies such as deep brain stimulation (DBS) and spinal cord stimulation (SCS). The mechanism of PD pain relief by DBS is thought to involve increased pain threshold to nociceptive stimulation, whereas the mechanism of SCS has not been elucidated. Objective: PD pain relief by SCS may involve modulation of the pain thresholds in the spinal cord segments and supra-spinal actions. Therefore, we investigated the effect of SCS in patients who underwent SCS for intractable PD pain in the lower extremities by measuring pain thresholds to thermal nociceptive stimulation of the lower (leg) and upper (hand) parts of the stimulated spinal segment during SCS-off and SCS-on using quantitative sensory testing to determine the pain threshold. Methods: Seven PD patients with SCS in the lower thoracic spinal cord underwent measurements of cold sensory threshold, warm sensory threshold, cold pain threshold (CPT), and heat pain threshold (HPT). Results: In upper part of the stimulated spinal segment, CPT was significantly decreased during SCS-on compared to SCS-off (p

Objective: To establish the utility of the additional evaluation of the P15 potential generated at the greater sciatic foramen in the tibial nerve somatosensory evoked potentials (SEPs) in diagnosing lumbar spinal stenosis (LSS). Methods: We retrospectively reviewed tibial nerve SEP findings in patients having MRI-confirmed LSS at the cauda equina or conus/epiconus region. P15 and N21 potentials were recorded and the following findings were defined as localizing abnormalities: 1) normal P15 latency either with prolonged P15-N21 interval or with absent N21; 2) decreased ratio of the N21 amplitude to P15 amplitude. As non-localizing abnormalities, N21 and P38 latencies were also evaluated. Tibial nerve F-wave findings were also investigated. Results: According to the entry criteria, 18 patients were included, 15 with cauda equina lesions and 3 with conus/epiconus lesions. Localizing abnormalities in SEPs were found in 67% of patients, achieving significantly higher sensitivity than delayed P38 latency (28%), and higher sensitivity than N21 abnormalities (39%), though this was not significant. Localizing abnormalities were observed even in 6 out of 11 patients lacking both sensory symptoms and signs. Tibial nerve F-wave was abnormal in 36% of 14 patients with F-wave examinations, whereas the localizing abnormalities in SEPs were found in 64% of the same patient population. P15 amplitude was depressed in 4 patients (22%), which may indicate the involvement of the dorsal root ganglion in LSS, although its latency was normal even for these patients. Conclusions: Tibial nerve SEPs with the recording of P15 and N21 potentials achieved sufficiently high sensitivity in diagnosing LSS. They have the advantage over F-wave in that they can localize the lesion at the cauda equina or conus/epiconus level. Significance: Tibial nerve SEPs are promising in evaluating LSS, especially in documenting sensory tract involvement in cases lacking sensory symptoms/signs.

The True Infection Rate (TIR) in the whole population of each country and the Infection Fatality Rate (IFR) for coronavirus disease 2019 (COVID-19) are unknown although they are important parameters. We devised a simple method to infer TIR and IFR based on the open data. The prevalence rate of the Polymerase Chain Reaction (PCR) tests among the population (Examination Rate; ER) and the positive rate of PCR tests (Infection Rate; IR) for 66 countries were picked up at a website 5 times from April 10th to June 13th, 2020, and the trajectory of each country was drawn over the IR vs. ER plot. IR and ER showed a strong negative correlation for some countries, and TIR was estimated by extrapolating the regression line when the correlation coefficient was between -0.99 and -1. True/Identified Case Ratio (TICR) and IFR were also calculated using the estimated TIR. The estimated TIR well coincided with local antibody surveys. Estimated IFR took on a wide range of values up to 10%: generally high in the Western countries. The estimated IFR of Singapore was very low (0.018%), which may be related to the reported gene mutation causing the attenuation of the viral virulence.

Background: Intravascular acute thrombectomy is recommended for acute cerebral infarction within 8 h of onset, based on several randomized controlled trials. However, standard treatment for cases outside these indications has not been established. Objective: Emergent superficial temporal artery (STA)-middle cerebral artery (MCA) bypass was performed within 72 h of onset for non-cardiogenic cerebral artery occlusive disease and the surgical outcomes are discussed. Methods: Retrospective review of 18 consecutive patients with non-cardiac cerebrovascular occlusive stroke who underwent emergent bypass surgery from September 2010 to August 2018. Surgical indications were determined as symptomatic ICA or MCA occlusive disease within 8–72 h after onset, and crescendo and/or progressive frequent transient ischemic attack, or impending stroke despite aggressive medical treatment with National Institutes of Health Stroke Scale (NIHSS) at 4 points or more, small cortical infarction (1/3 or less), and observed perfusion-diffusion mismatch. Results: Surgical outcome was good recovery in 2 patients, moderate disability in 8, severe disability in 6, and death in 2 patients. Favorable outcome was achieved in 55.6%, and poor outcome in 44.4%. No patient showed enlargement of the area of cerebral infarction. The value of the BRS significantly improved after surgery in favourable outcome group. No patient suffered any complication related to surgical intervention including hemorrhagic complications. Conclusions: Emergent STA-MCA bypass surgery can improve clinical outcome and reduce the risk of morbidity under strict surgical indications, so could be an option for acute stage revascularization after ineffective thrombolytic therapy for non-cardiac acute cerebrovascular stroke.

Background: Dural arteriovenous fistulas (DAVF) complicate intracranial hemorrhages that are secondary to cortical venous reflux (CVR). Clinicians usually pay attention to CVR but not to other uncommon etiologies in hemorrhagic cases. Here, we report the rare case of a ruptured pial feeder aneurysm arising from the posterior inferior cerebellar artery (PICA) that was successfully treated with endovascular surgery. Case description: An 81-year-old man was transferred to the emergency department of our hospital because of sudden onset of vertigo and vomiting. Head computed tomography showed a hyperdense area of up to 2.6 cm in the cerebellar vermis, intraventricular hemorrhage in the fourth ventricle, and subarachnoid hemorrhage in the cerebellopontine cistern. Digital subtraction angiography (DSA) showed a torcular DAVF. CVR was observed in the bilateral cerebellar veins (Borden type 3, Cognard type 4). DSA revealed a small aneurysm in the vermian branch of the left PICA feeding the DAVF. Because the aneurysm was arising from the vermian branch itself, we decided to occlude it with 12.5% N-butyl-2-cyanoacrylate. The vermian branch harboring the aneurysm was successfully obliterated. Rebleeding did not occur postoperatively. Conclusions: The CVR is a common etiology of intracranial hemorrhage caused by DAVF. However, clinicians should be aware that the pial feeder may also contribute to hemorrhagic complications. Our case illustrates the significance of the existence of the pial feeder in hemorrhagic DAVF and the potential contribution of an aneurysm arising from the pial feeder to the etiology. Care should be taken not to overlook the pial feeder on radiologic imaging, and appropriate surgical management should be performed to prevent rupture.

Central dural tenting sutures are surgical routine procedure in craniotomy which requires passing the thread through a small bone hole, which is time consuming and both physically and mentally stressful. We have developed a novel surgical device to easily perform these procedures and to reduce stress. This study evaluated the convenience, ease, and accuracy compared to conventional methods. We evaluated the time taken using the bone hole threader with an artificial bone model with 10 bone holes. The time required to pass the sutures through the bone hole was compared after 11 neurosurgeons performed using each of three methods twice: one surgeon and another assistant using the conventional method, one surgeon using the bone hole threader, and one surgeon and another assistant using the bone hole threader. These results were statistically analyzed using SPSS. Mean time reduction of 15.9 s was obtained for the bone threader use by one surgeon compared with conventional method by two operators (p = 0.03). Mean time reduction of 24 s was obtained for the bone threader use by two operators compared with one operator (p

Background: Seizure frequency after neurosurgery with craniotomy has been widely reported. Postoperative consciousness recovery may be prolonged in such cases due to seizures or factors related to the underlying pathology and/or surgical procedures. However, it remains unclear whether prophylactic administration of antiseizure drugs is effective. Recently, continuous administration of levetiracetam (LEV) was shown to effectively reduce postoperative seizure frequency. Here, we aimed to confirm the postoperative efficacy of LEV and investigate its potential to aid in consciousness level recovery followed by functional recovery. Method: This retrospective, single-center study analyzed the data of 61 patients who underwent supratentorial craniotomy and were divided into two groups: a continuous prophylactic LEV administration group (LEV group; 2000 mg/day for 14 days; 41 patients) or non-continuous prophylactic administration group (Control group; phenytoin 250 mg/day only on the operative day and postoperative day 1; 20 patients). Seizure frequency, the Glasgow coma scale (GCS), and modified Rankin scale (mRS) were evaluated and compared within and between groups. Results: Average age (years ± SD) was 64.0 ± 17.8 in the LEV and 64.3 ± 13.6 in the Control group. Preoperative seizure frequency was 9.8% in the LEV and 0% in the Control group, and postoperatively, it was 4.9% in the LEV and 25% in the Control group. While there were no preoperative differences in GCS between the groups, the postoperative GCS significantly improved in the LEV group starting on postoperative day 3 but only showed improvement in the Control group starting on postoperative day 14. Functional recovery as determined by the mRS indicated significant improvement in the LEV group on postoperative day 8, whereas the control group showed no significant recovery even on postoperative day 14. Conclusion: Continuous LEV administration after neurosurgical operation with craniotomy accelerates recovery from consciousness disturbance and could improve outcomes by allowing aggressive early neurorehabilitation.

Objective: We report on two patients with amyotrophic lateral sclerosis (ALS) complaining of sudden-onset difficulty in finger elevation. Case report: A 65-year-old man (the first patient) and a 66-year-old man (the second patient) suddenly became aware of difficulty in finger elevation of one hand. They were not aware of any other symptoms prior to the onset. In the first patient, cerebral infarction at the precentral gyrus was initially suspected. In the second patient, cervical spondylosis was initially suspected, and cervical spine surgery was planned. However, needle EMG revealed widespread neurogenic changes and abundant fasciculation potentials for both patients. Widespread weakness emerged in time and relentlessly progressed, and finally the diagnosis of ALS was made. In both cases, notable weakness in the extensor digitorum (ED) muscle with relatively mild weakness in the other muscles in the affected limb was a characteristic finding. Loss of one motor unit in ED that has already enlarged due to reinnervation must have caused sudden awareness of the weakness. Significance: Clinicians should recognize the presence of ALS patients with a sudden-onset history because the risk of initial misdiagnosis is high for such patients. Keywords: Amyotrophic lateral sclerosis, Sudden-onset, Finger elevation, Needle electromyography, Manual muscle testing