Embolic MCA Stroke Treated With tPA and TICI-3 Mechanical Thrombectomy Complicated by Hemiballismus: A Case Study and Literature Review

ABSTRACT This report examines the etiology of hemiballistic movements that began 24 hours after a 63-year-old male with vascular risk factors received tissue plasminogen activator (tPa) and thrombolysis in cerebral ischemia 3 (TICI3) thrombectomy for a left middle cerebral artery (MCA) ischemic stroke. The clinical course was reviewed from an admission at a large academic institution where assessments included physical exams, head and neck computed tomography angiography (CTA), and head magnetic resonance imaging (MRI) without contrast. The patient’s initial physical exam was consistent with a left MCA syndrome and included a National Institute of Health Stroke Scale (NIHSS) of 20. CTA showed an embolic M2 occlusion. After tPA and TICI 3 thrombectomy, NIHSS improved to 3 for dysarthria, facial weakness, and language deficits. MRI showed left insular diffusion restriction. New right-sided hemiballistic movements began 24 hours after treatment. At his six-week follow-up outpatient appointment, the movements were no longer present, and his neurologic exam was unremarkable, including an NIHSS of zero. No prior cases of hemiballism have been reported as a likely complication of treatment with tPa and thrombectomy. The globus pallidus is the suspected origin of the ballistic movements either from a decreased insular signal or embolic event during treatment. As stroke interventions improve, the susceptibility of certain tissues to brief ischemic events during treatment must be assessed.

Non-ketotic Hyperglycemia Chorea-Ballismus and Intracerebral Hemorrhage: A Case Report and Literature Review

Non-ketotic hyperglycemia chorea-ballismus (NKH-CB) is a rare metabolical syndrome secondary to the hyperglycemic condition, which is characterized by a triad of acute or subacute hemichorea-hemiballismus, hyperglycemic state, and unique abnormalities limited to the striatum on neuroimaging. Several related case studies on this disorder have been reported previously, but NKH-CB had never been associated with intracerebral hemorrhage (ICH). Herein, we report an uncommon case of NKH-CB and ICH that occurred simultaneously in one patient, which provides a challenge for clinicians in making a correct diagnosis. An 88-year-old woman with a long-term history of poor-controlled type 2 diabetes mellitus and hypertension, who presented with a sudden-onset headache, restlessness, severe bilateral choreiform and ballistic movements, elevated levels of glucose and osmolality in the serum, an increased white blood cell count, and two-type hyperdense signs on CT imaging, was finally diagnosed with NKH-CB and ICH. Despite administrated active treatments, the patient's clinical status did not improve and ultimately passed away. This case is reported to remind clinicians to consider the possibility of NKH-CB when patients present sudden-onset choreiform and ballistic movements. It is also the first entity with two-type hyperdense signs on CT imaging simultaneously, which helps us distinguish NKH-CB from ICH more intuitively.

Detraining attenuation during the COVID-19 pandemic: practical considerations for home-based strength and power training

The COVID-19 pandemic that scattered across the world in 2020 has required collective action to control the transmission of the disease. Among the measures, social distancing has been widely adopted, aiming to reduce contact and people gathering. With the limited access to training places that have equipment and a variety of loads for strength and power training, alternative strategies to be carried out in the domestic environment are important for maintaining physical conditioning and mitigating the deleterious effects of detraining. Based on the available scientific literature, this article presents practical recommendations for strength training in the home environment. It is recommended to perform exercises that employ self-body weight, household items and, when available, dumbbells and elastic bands. Whenever using low loads (30-50% of 1 repetition maximum), performing the sets until the concentric failure seems to be necessary to optimize gains in strength and muscle mass. The practice of physical exercises should be performed on most days of the week (> 5 days/week), combined with domestic and leisure activities that involve the movement of the whole body. For maintenance and / or development of muscle power, ballistic movements must be included, in the presence or absence of external loads.Keywords: strength training, power, detraining, COVID-19.

A size principle for leg motor control in Drosophila

SummaryTo move the body, the brain must precisely coordinate patterns of activity among diverse populations of motor neurons. In many species, including vertebrates, the motor neurons innervating a given muscle fire in a specific order that is determined by a gradient of cellular size and electrical excitability. This hierarchy allows premotor circuits to recruit motor neurons of increasing force capacity in a task-dependent manner. However, it remains unclear whether such a size principle also applies to species with more compact motor systems, such as the fruit fly, Drosophila melanogaster, which has just 53 motor neurons per leg. Using in vivo calcium imaging and electrophysiology, we found that genetically-identified motor neurons controlling flexion of the fly tibia exhibit a gradient of anatomical, physiological, and functional properties consistent with the size principle. Large, fast motor neurons control high force, ballistic movements while small, slow motor neurons control low force, postural movements. Intermediate neurons fall between these two extremes. In behaving flies, motor neurons are recruited in order from slow to fast. This hierarchical organization suggests that slow and fast motor neurons control distinct motor regimes. Indeed, we find that optogenetic manipulation of each motor neuron type has distinct effects on the behavior of walking flies.

Convection-Enhanced Delivery of Muscimol Into the Bilateral Subthalamic Nuclei of Nonhuman Primates

BACKGROUND Muscimol is a gamma-aminobutyric acid receptor agonist that selectively and temporarily inhibits neurons. Local bolus injection of muscimol has been used experimentally to inhibit neuronal populations within discrete anatomical structures and discern their physiological function. OBJECTIVE To determine the safety and behavioral effects of convection-enhanced delivery of muscimol into the bilateral subthalamic nuclei (STN) of nonhuman primate rhesus macaques (NHPs). METHODS Six awake NHPs underwent co-infusion of gadolinium-diethylenetriamine pentaacetic acid (Gd-DTPA), a surrogate magnetic resonance imaging (MRI) tracer, with increasing concentrations of muscimol for behavioral and histological assessment. Three other NHPs were co-infused with Gd-DTPA and 3H-muscimol into the STN to determine muscimol distribution by MRI and autoradiography. Two NHPs underwent microcatheter implantation without muscimol infusion for control comparison. RESULTS MRI revealed selective and complete perfusion of the bilateral STN in animals infused with Gd-DTPA and muscimol. No abnormal movements occurred at 0.125 mM. Muscimol doses between 0.25 and 4.4 mM resulted in transient, dose-dependent hyperkinesia. Muscimol (8.8 mM) resulted in severe bilateral dyskinesias, ballistic movements, and sedation. An 88.8 mM dose produced unresponsiveness in 1 animal. Infusion-related pathological abnormities or toxicity was not present on histological examination. MRI distribution of co-infused Gd-DTPA was similar to autoradiographic distribution of 3H-muscimol (Vd; R = 0.94). Mean Vd of infused animals was 37.9 mm3 ± 11.7 mm3 and mean Vd: Vi 7.6 ± 2.3. CONCLUSION Bilateral convection-enhanced delivery of muscimol into the primate STN resulted in dose-related hyperkinetic movements that resolved after stopping the infusion. Muscimol was not toxic to brain tissue. Gd-DTPA accurately tracked muscimol distribution.

Head Rotation Movement Times

Objective: The aim of this study was to measure head rotation movement times in a Fitts’ paradigm and to investigate the transition region from ballistic movements to visually controlled movements as the task index of difficulty (ID) increases. Background: For head rotation, there are gaps in the knowledge of the effects of movement amplitude and task difficulty around the critical transition region from ballistic movements to visually controlled movements. Method: Under the conditions of 11 ID values (from 1.0 to 6.0) and five movement amplitudes (20° to 60°), participants performed a head rotation task, and movement times were measured. Results: Both the movement amplitude and task difficulty have effects on movement times at low IDs, but movement times are dependent only on ID at higher ID values. Movement times of participants are higher than for arm/hand movements, for both ballistic and visually controlled movements. The information-processing rate of head rotational movements, at high ID values, is about half that of arm movements. Conclusion: As an input mode, head rotations are not as efficient as the arm system either in ability to use rapid ballistic movements or in the rate at which information may be processed. Application: The data of this study add to those in the review of Hoffmann for the critical IDs of different body motions. The data also allow design for the best arrangement of display that is under the design constraints of limited display area and difficulty of head-controlled movements in a data-inputting task.