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Cortical reorganization in patients with subcortical hemiparesis: neural mechanisms of functional recovery and prognostic implication

Yukihiko Fujii and Tsutomu Nakada

Object. A systematic investigation on cortical reorganization in patients with hemiparesis of a subcortical origin, with special emphasis on functional correlates, was conducted using functional magnetic resonance (fMR) imaging performed on a 3-tesla system specifically optimized for fMR imaging investigation.

Methods. The study group included 46 patients with hemiparesis (25 with right and 21 with left hemiparesis) and 30 age-matched healthy volunteers as controls. All study participants were originally right handed. The characteristics of the lesion were putaminal hemorrhage in 19 patients, thalamic hemorrhage in 10 patients, and striatocapsular bland infarction in 17 patients.

Functional recovery in subcortical hemiparesis showed two distinct phases of the recovery process involving entirely different neural mechanisms. Phase I is characterized by the process of recovery and/or reorganization of the primary system. Successful recovery of this system is typically reached within 1 month after stroke onset. Its clinical correlate is a rapid recovery course and significant recovery of function within 1 month of stroke onset. Failure of recovery of the primary system shifts the recovery process to Phase II, during which reorganization involving the ipsilateral pathway takes place. The clinical correlate of Phase II is a slow recovery course with variable functional outcome.

Conclusions. Effective functional organization of the ipsilateral pathway, as identified by linked activation of the ipsilateral primary sensorimotor cortex and contralateral anterior lobe of the cerebellum, is correlated with a good prognostic outcome for patients in the slow recovery group. A high degree of connectivity between supplementary motor areas, bilaterally, appears to influence functional recovery adversely.

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Hematoma Enlargement in Intracerebral Hemorrhage

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Thrombin—Antithrombin Complex Levels in Subarachnoid Hemorrhage

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High-resolution T2-reversed magnetic resonance imaging on a high magnetic field system

Technical note

Yukihiko Fujii, Naoki Nakayama, and Tsutomu Nakada

Because of the high signal-to-noise (S/N) ratio, T2-weighted images obtained using high-field magnetic resonance (MR) imaging systems can be expected to provide high anatomical and contrast resolution. Furthermore, the improved structural and contrast resolution of these high S/N T2-weighted images can be processed for optimum perceptual resolution through the application of gray-scale reversal and expansion of the gray-scale window, known as T2-reversed (T2R) imaging. In this study, the authors investigated high-resolution T2R MR imaging performed on a high-field (3-tesla) system for its clinical utility in detecting various physiological and pathological conditions.

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A true posterior communicating artery aneurysm: variations in the relationship between the posterior communicating artery and the oculomotor nerve

Case illustration

Takatoshi Sorimachi, Yukihiko Fujii, and Takeo Nashimoto

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Coerced training of the nondominant hand resulting in cortical reorganization: a high-field functional magnetic resonance imaging study

Tsutomu Nakada, Yukihiko Fujii, and Ingrid L. Kwee

Object. The authors investigated brain strategies associated with hand use in an attempt to clarify genetic and nongenetic factors influencing handedness by using high-field functional magnetic resonance imaging.

Methods. Three groups of patients were studied. The first two groups comprised individuals in whom handedness developed spontaneously (right-handed and left-handed groups). The third group comprised individuals who were coercively trained to use the right hand and developed mixed handedness, referred to here as trained ambidexterity. All trained ambidextrous volunteers were certain that they were innately left-handed, but due to social pressure had modified their preferred hand use for certain tasks common to the right hand.

Although right-handed and left-handed volunteers displayed virtually identical cortical activation, involving homologous cortex primarily located contralateral to the hand motion, trained ambidextrous volunteers exhibited a clearly unique activation pattern. During right-handed motion, motor areas in both hemispheres were activated in these volunteers. During left-handed motion, the right supplemental motor area and the right intermediate zone of the anterior cerebellar lobe were activated significantly more frequently than observed in naturally right-handed or left-handed volunteers.

Conclusions. The results provide strong evidence that cortical organization of spontaneously developed right- and left-handedness involves homologous cortex primarily located contralateral to the hand motion, and this organization is likely to be prenatally determined. By contrast, coerced training of the nondominant hand during the early stages of an individual's development results in mixed handedness (trained ambidexterity), indicating cortical reorganization.

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Striatal hyperintensity on T1-weighted magnetic resonance images and high-density signal on computerized tomography scans obtained in patients with hyperglycemia and no involuntary movement

Report of two cases

Takatoshi Sorimachi, Yukihiko Fujii, Naoto Tsuchiya, and Masatsune Saito

✓ The authors report on two patients in whom an increased signal on T1-weighted magnetic resonance images and a high-density signal on computerized tomography scans of the striatum were demonstrated, both of which were associated with nonketotic hyperglycemia. Involuntary movements, which have been present in all previously reported cases, were not observed in either patient at any time during the entire course of illness. One patient displayed hemiparesis, whereas the other had dementia, gait disturbance, and urinary incontinence. Clinical and radiological abnormalities improved on control of blood glucose levels. Invasive studies, including biopsy procedures, should be avoided on encountering this disease given the good prognosis that results from simple medical treatment.

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Clinical application of three-dimensional anisotropy contrast magnetic resonance axonography

Technical note

Tsutomu Nakada, Naoki Nakayama, Yukihiko Fujii, and Ingrid L. Kwee

✓ The utility of three-dimensional anisotropy contrast (3DAC) magnetic resonance (MR) axonography, a method sensitive to neuronal fibers and their directionality, was investigated in the clinical setting using a 3-tesla MR imaging system based on a General Electric Signa platform. The study focused on healthy volunteers and patients with common structural central nervous system disorders, namely chronic infarction, brainstem cavernous hemangioma, supratentorial meningioma, and astrocytoma. Three orthogonal anisotropic diffusion-weighted images were first obtained. Three primary colors were each assigned to a diffusion-weighted image, respectively, and the images were subsequently combined into a single-color image in full-color spectrum (3DAC MR axonography image). Fiber-tract definition in the cerebral peduncle of the midbrain of healthy volunteers showed intersubject variation, with two general patterns recognized: dispersed (60% of cases) and compact (40% of cases). Pathological alterations in the fiber tracts were readily identified in cases involving wallerian degeneration of the pyramidal tract, as illustrated in the cases of chronic infarction. Displacement of major tracts, such as the medial lemniscus or corticospinal tract, as well as fiber directionality, was also easily recognized in cases of mass lesions. As an imaging method uniquely capable of providing information regarding axonal connectivity, 3DAC MR axonography appears to have promising potential for routine clinical application.

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Predictors of hematoma enlargement in patients with intracerebral hemorrhage treated with rapid administration of antifibrinolytic agents and strict blood pressure control

Takatoshi Sorimachi, Yukihiko Fujii, Kenichi Morita, and Ryuichi Tanaka


Hematoma enlargement is a major cause of poor outcome in patients with intracerebral hemorrhage (ICH). A combination of rapid administration of antifibrinolytics and strict blood pressure (BP) control for prevention of hematoma enlargement has been recently reported. The authors examined the incidence and predictors of hematoma enlargement in patients with ICH who were treated with this therapy.


Rapid administration of antifibrinolytic agents consisted of intravenous administration of 2 g tranexamic acid over 10 minutes. Systolic BP was strictly maintained below 150 mm Hg using intravenous nicardipine. Immediately after diagnosis of ICH on computed tomography (CT), 188 patients who were admitted within 24 hours of symptom onset were treated with a combination of rapid administration of antifibrinolytic agents and BP control. Hematoma enlargement was determined on the basis of a second CT scan performed the day after admission. Several factors, including those that have been reported to affect hematoma enlargement, were compared between patients with and without hematoma enlargement.

Hematoma enlargement (≥ 20% volume increase) was observed in eight (4.3%) of 188 patients. Previous use of antiplatelet agents was significantly more frequent in patients with hematoma enlargement (p < 0.05). No significant between-group difference was found for any other factors.


Previous use of antiplatelet agents was a predictor of hematoma enlargement in patients with ICH treated with rapid administration of antifibrinolytic agents and BP control.

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Clinicopathological factors related to regrowth of vestibular schwannoma after incomplete resection

Clinical article

Masafumi Fukuda, Makoto Oishi, Tetsuya Hiraishi, Manabu Natsumeda, and Yukihiko Fujii


The authors retrospectively analyzed various clinicopathological factors to determine which are related to regrowth during a long-term follow-up period in patients who underwent incomplete vestibular schwannoma (VS) resection.


This study involved 74 patients (25 men and 49 women) in whom a VS was treated surgically via the lateral suboccipital approach, and who had postoperative follow-up periods exceeding 5 years. The mean follow-up was 104.1 months (range 60–241 months), and the mean patient age at surgery was 48.1 years (range 19–75 years). The tumors ranged in size from 0 mm (localized within the internal auditory canal) to 56 mm (28.3 ± 12.2 mm [mean ± SD]).


Gross-total resection (GTR) was performed in 41 (55%) of the 74 patients; subtotal resection ([STR]; 90–99%) in 25 (34%); and partial resection ([PR]; < 90%) in 8 (11%). Regrowth rates in the GTR, STR, and PR groups were 2.4% (1 of 41 cases), 52% (13 of 25), and 62.5% (5 of 8), respectively, and the times to regrowth ranged from 6 to 76 months (median 31.9 months). The regrowth-free survival curves differed significantly between the complete (GTR) and incomplete (STR and PR) resection groups. Eighteen (54.5%) of the 33 patients who underwent incomplete resection showed evidence of regrowth during follow-up. Univariate and multivariate analyses of various factors revealed that both the thickness of the residual tumor, based on MR imaging after surgery, and the MIB-1 index were positively related to residual tumor regrowth. The receiver operating characteristic curves, plotted for both the thickness of the residual tumor and the MIB-1 index, identified the optimal cutoff points for these values as 7.4 mm (sensitivity 83.3%, specificity 86.7%) and 1.6 (sensitivity 83.3%, specificity 66.7%), respectively.


Greater residual tumor thickness, based on MR imaging after the initial surgery, and a higher MIB-1 index are both important factors related to postoperative tumor regrowth in patients who have undergone incomplete VS resection. These patients require frequent neuroimaging investigation during follow-up to assure early detection of tumor regrowth.