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Delayed gait recovery with recovery of an injured corticoreticulospinal tract in a chronic hemiparetic patient

View Article: PubMed Central - PubMed

ABSTRACT

Objectives:: We report on a chronic hemiparetic patient whose gait recovery was delayed until healing of an injured corticoreticulospinal tract (CRT), which was demonstrated on diffusion tensor tractography (DTT).

Case presentation:: A 71-year-old female presented with complete paralysis of the right extremities resulting from a spontaneous intracerebral hemorrhage. At 5 months after onset, when she was admitted for rehabilitation after undergoing rehabilitation at the previous university hospital, she presented with severe weakness of the right leg (manual muscle test: 0 ∼ 2- score) and could not even stand. She received comprehensive rehabilitative therapy for 32 months after the onset. Motor weakness of her right leg improved to the point that she was able to extend her knee on gravity-eliminated position at 11 months and against some resistance at 30 months after onset. She was able to walk independently at 30 months after onset.

Results:: The left CRT was discontinuous at the basal ganglia level on 5-month DTT. This discontinuation elongated to the cerebral cortex on 32-month DTT, whereas on 32-month DTT, the right CRT had become thicker compared with that on 5-month DTT.

Conclusions:: An injured CRT healed in a patient who was able to walk independently after approximately 2 years of rehabilitation starting 5 months after the onset of intracerebral hemorrhage.

No MeSH data available.


Related in: MedlinePlus

A, Brain computed tomography (CT) images show hematomas in the left corona radiata and basal ganglia at onset and T2-weighted magnetic resonance (MR) images show a leukomalactic lesion in the left corona radiata and basal ganglia at 5 months after onset. B, Results of diffusion tensor tractography (DTT). The left corticospinal tract (CST) shows narrowing compared with the right CST on 5-month DTT. Similar findings were observed for both CSTs on 32-month DTT. The left corticoreticulospinal tract (CRT) shows discontinuation at the basal ganglia level on 5-month DTT (blue arrow) and this discontinuation is elongated to the cerebral cortex on 32-month DTT (red arrows), whereas on 32-month DTT, the right CRT has become thicker than it was on the 5-month DTT (green arrow). C, Results of DTT for the CST and CRT in a normal control.
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Figure 1: A, Brain computed tomography (CT) images show hematomas in the left corona radiata and basal ganglia at onset and T2-weighted magnetic resonance (MR) images show a leukomalactic lesion in the left corona radiata and basal ganglia at 5 months after onset. B, Results of diffusion tensor tractography (DTT). The left corticospinal tract (CST) shows narrowing compared with the right CST on 5-month DTT. Similar findings were observed for both CSTs on 32-month DTT. The left corticoreticulospinal tract (CRT) shows discontinuation at the basal ganglia level on 5-month DTT (blue arrow) and this discontinuation is elongated to the cerebral cortex on 32-month DTT (red arrows), whereas on 32-month DTT, the right CRT has become thicker than it was on the 5-month DTT (green arrow). C, Results of DTT for the CST and CRT in a normal control.

Mentions: A 71-year-old right-handed female presented with complete paralysis of the right extremities [Medical Research Council (MRC): 0/5] at the onset of a spontaneous intracerebral hemorrhage (ICH) (Table 1).[17] The volume of hemorrhage (22950.7 mm3), was measured by Insight Toolkit - SNake Automatic Partitioning program (University of Pennsylvania, Philadelphia, PA). No previous medical history of neurological, physical, or psychiatric illness was observed except for hypertension and diabetes. Five months after onset, she was admitted to the rehabilitation department of a university hospital after undergoing rehabilitation at a different university hospital. Brain magnetic resonance (MR) images taken upon admission showed a leukomalactic lesion in the left corona radiata and basal ganglia (Fig. 1A). For measurement of gait function, functional ambulation category (FAC, full mark: 5 points) was measured. She presented with mild conduction aphasia, severe weakness of the right leg (MRC: hip flexor; 2-, knee extensor: 0, and ankle dorsiflexor: 0) and could not even stand (FAC: 0 point) (Table 1). She began comprehensive rehabilitative therapy, which included neurotropic drugs (methylphenidate, pramipexole, amantadine, levodopa, and venlafaxine), movement therapy, and neuromuscular electrical stimulation of the right knee extensor and ankle dorsiflexor.[15,18–22] Movement therapy was conducted 30 min/d and 5 times per week in our physical and occupational therapy department. Her rehabilitation was continued until 32 months after onset at the inpatient clinic of our hospital and 2 other local rehabilitation hospitals, and the outpatient clinic of the rehabilitation department of our hospital. Motor weakness of her right leg improved to the point that she was able to extend her knee on gravity-eliminated position at 11 months and against some resistance at 30 months after onset. She was able to walk independently at 30 months after her stroke (FAC: 3.5 points). Seven age and sex-matched normal control subjects (mean age: 67.9 ± 5.0 years, range: 62–77 years) with no history of neurological disease were recruited for this study. The patient and all normal control subjects provided informed consent, and the study protocol was approved by Yeungnam University Hospital institutional review board.


Delayed gait recovery with recovery of an injured corticoreticulospinal tract in a chronic hemiparetic patient
A, Brain computed tomography (CT) images show hematomas in the left corona radiata and basal ganglia at onset and T2-weighted magnetic resonance (MR) images show a leukomalactic lesion in the left corona radiata and basal ganglia at 5 months after onset. B, Results of diffusion tensor tractography (DTT). The left corticospinal tract (CST) shows narrowing compared with the right CST on 5-month DTT. Similar findings were observed for both CSTs on 32-month DTT. The left corticoreticulospinal tract (CRT) shows discontinuation at the basal ganglia level on 5-month DTT (blue arrow) and this discontinuation is elongated to the cerebral cortex on 32-month DTT (red arrows), whereas on 32-month DTT, the right CRT has become thicker than it was on the 5-month DTT (green arrow). C, Results of DTT for the CST and CRT in a normal control.
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Figure 1: A, Brain computed tomography (CT) images show hematomas in the left corona radiata and basal ganglia at onset and T2-weighted magnetic resonance (MR) images show a leukomalactic lesion in the left corona radiata and basal ganglia at 5 months after onset. B, Results of diffusion tensor tractography (DTT). The left corticospinal tract (CST) shows narrowing compared with the right CST on 5-month DTT. Similar findings were observed for both CSTs on 32-month DTT. The left corticoreticulospinal tract (CRT) shows discontinuation at the basal ganglia level on 5-month DTT (blue arrow) and this discontinuation is elongated to the cerebral cortex on 32-month DTT (red arrows), whereas on 32-month DTT, the right CRT has become thicker than it was on the 5-month DTT (green arrow). C, Results of DTT for the CST and CRT in a normal control.
Mentions: A 71-year-old right-handed female presented with complete paralysis of the right extremities [Medical Research Council (MRC): 0/5] at the onset of a spontaneous intracerebral hemorrhage (ICH) (Table 1).[17] The volume of hemorrhage (22950.7 mm3), was measured by Insight Toolkit - SNake Automatic Partitioning program (University of Pennsylvania, Philadelphia, PA). No previous medical history of neurological, physical, or psychiatric illness was observed except for hypertension and diabetes. Five months after onset, she was admitted to the rehabilitation department of a university hospital after undergoing rehabilitation at a different university hospital. Brain magnetic resonance (MR) images taken upon admission showed a leukomalactic lesion in the left corona radiata and basal ganglia (Fig. 1A). For measurement of gait function, functional ambulation category (FAC, full mark: 5 points) was measured. She presented with mild conduction aphasia, severe weakness of the right leg (MRC: hip flexor; 2-, knee extensor: 0, and ankle dorsiflexor: 0) and could not even stand (FAC: 0 point) (Table 1). She began comprehensive rehabilitative therapy, which included neurotropic drugs (methylphenidate, pramipexole, amantadine, levodopa, and venlafaxine), movement therapy, and neuromuscular electrical stimulation of the right knee extensor and ankle dorsiflexor.[15,18–22] Movement therapy was conducted 30 min/d and 5 times per week in our physical and occupational therapy department. Her rehabilitation was continued until 32 months after onset at the inpatient clinic of our hospital and 2 other local rehabilitation hospitals, and the outpatient clinic of the rehabilitation department of our hospital. Motor weakness of her right leg improved to the point that she was able to extend her knee on gravity-eliminated position at 11 months and against some resistance at 30 months after onset. She was able to walk independently at 30 months after her stroke (FAC: 3.5 points). Seven age and sex-matched normal control subjects (mean age: 67.9 ± 5.0 years, range: 62–77 years) with no history of neurological disease were recruited for this study. The patient and all normal control subjects provided informed consent, and the study protocol was approved by Yeungnam University Hospital institutional review board.

View Article: PubMed Central - PubMed

ABSTRACT

Objectives:: We report on a chronic hemiparetic patient whose gait recovery was delayed until healing of an injured corticoreticulospinal tract (CRT), which was demonstrated on diffusion tensor tractography (DTT).

Case presentation:: A 71-year-old female presented with complete paralysis of the right extremities resulting from a spontaneous intracerebral hemorrhage. At 5 months after onset, when she was admitted for rehabilitation after undergoing rehabilitation at the previous university hospital, she presented with severe weakness of the right leg (manual muscle test: 0 ∼ 2- score) and could not even stand. She received comprehensive rehabilitative therapy for 32 months after the onset. Motor weakness of her right leg improved to the point that she was able to extend her knee on gravity-eliminated position at 11 months and against some resistance at 30 months after onset. She was able to walk independently at 30 months after onset.

Results:: The left CRT was discontinuous at the basal ganglia level on 5-month DTT. This discontinuation elongated to the cerebral cortex on 32-month DTT, whereas on 32-month DTT, the right CRT had become thicker compared with that on 5-month DTT.

Conclusions:: An injured CRT healed in a patient who was able to walk independently after approximately 2 years of rehabilitation starting 5 months after the onset of intracerebral hemorrhage.

No MeSH data available.


Related in: MedlinePlus