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A 36-year-old man with a 21-year history of Crohn's disease suddenly developed left hemiparesis. He did not have atherosclerotic risk factors on admission, but he had marked dehydration which was likely due to prolonged home intravenous hyper-alimentation. Brain MRI revealed lacunar infarction in the right anterior corona radiata. An anticoagulation drug and a free-oxide scavenger successfully reversed his neurological deficits almost completely. Stroke in young adults less than 40 years old is extremely rare; therefore, we conclude that Crohn's disease can be a risk factor for acute ischemic stroke in our case, due most probably to dehydration and other complex mechanisms.

Lower urinary tract function was studied in 10 patients with the anterior spinal artery syndrome. In the acute stage all patients had complete urinary retention. Cystometry in 3 patients showed detrusor areflexia. At a neurologically stable stage 9 patients could void and 1 had urinary retention during the preceding 7 years. Cystometric bladder capacities at first and maximum desire to void were decreased in 8 patients and normal in 2. Detrusor hyperreflexia was noted in 8 patients, a normal bladder in 1 and detrusor areflexia in 1. External urethral sphincter electromyography revealed detrusor-sphincter dyssynergia in 4 patients and normal findings in 6. We conclude that the vesicomotor dysfunction in this syndrome is similar to that of traumatic spinal cord injury except that bladder sensation is preserved. The latter finding indicates that at least some of the bladder sensation travels via the posterior columns of the spinal cord.

Clinical involvement of the CNS in sarcoidosis is seen in about 5% of patients.1 The most common affected sites are the basal leptomeninges and the region of the floor of the third ventricle. However, primary involvement of the spinal cord is much less common.1 It may cause serious neurological deficits below the affected level of the lesion. Here we describe a case of spinal cord sarcoidosis with an unusual presentation: autonomic dysreflexia due to neurogenic bladder dysfunction. A 42 year old woman began to have a slowly progressive spastic gait, left hand numbness, urinary urgency/frequency, and voiding difficulty which worsened gradually for a year. She underwent C2–7 laminoplasty for a relief of C4–6 cervical disc herniation where mild cord swelling was present. However, her gait difficulty ameliorated only for 2 weeks. Two months later she became unable to walk without an aid. Spinal MRI disclosed C2–7 cord swelling. She also developed bilateral hilar lymphadenopathy, ocular uveitis, and an increased serum concentration of angiotensin converting enzyme (ACE). Endoscopic lymph node biopsy showed non-caseating epithelioid granuloma. These findings and the clinical features confirmed the diagnosis of spinal cord sarcoidosis. She underwent steroid pulse therapy (1000 mg/day of intravenous methylprednisolone over 3 succeeding days) and started taking oral prednisolone (60 mg/day) with benefit. Steroids were tapered to 40 mg every other day and 4 months later she was referred to our hospital. However, her gait difficulty …

OBJECTIVES Urinary dysfunction is a prominent autonomic feature in Parkinson9s disease (PD) and multiple system atrophy (MSA), which is not only troublesome but also a cause of morbidity in these disorders. Recent advances in investigative uroneurology offer a better insight into the underlying pathophysiology and appropriate management for urinary dysfunction. METHODS twenty one patients with PD (15 men, six women, mean age 64 (49–76), mean disease duration 4 years (1–8 years), median Hoehn and Yahr grade 3 (1–4), all taking 300 mg/day of levodopa (100–500 mg)) and 15 with MSA (eight men, seven women, mean age 59 (48–72), mean disease duration 3 years (0.5–6 years)) were recruited. Videourodynamic and sphincter motor unit potential analyses in the patients with PD and MSA were carried out, looking for distinguishing hallmarks that might be useful in the differential diagnosis of these two diseases. RESULTS Urinary symptoms were found in 72% of patients with PD and in 100% with MSA. Filling phase abnormalities in the videourodynamic study included detrusor hyperreflexia in 81% of patients with PD and 56% with MSA, and uninhibited external sphincter relaxation in 33% of patients with PD and 33% of those with MSA. However, open bladder neck at the start of filling was not seen in patients with PD but was present in 53% of those with MSA, suggestive of internal sphincter denervation. Sphincter motor unit potential analysis showed neurogenic motor unit potentials in 5% of patients with PD and in 93% of those with MSA, suggestive of external sphincter denervation. On voiding, detrusor-external sphincter dyssynergia was not seen in patients with PD but was present in 47% of those with MSA. Pressure-flow analysis showed that the Abrams-Griffiths number, a grading of urethral obstruction (outflow obstruction >40), in PD (40 in women and 43 in men) was larger than that in MSA (12 in women and 28 in men). Weak detrusor in PD (66% of women and 40% of men) was less common than that in MSA (71% of women and 63% of men). Postmicturition residuals >100 ml were absent in patients with PD but were present in 47% of patients with MSA. CONCLUSION Patients with PD had less severe urinary dysfunction with little evidence of internal or external sphincter denervation, by contrast with the common findings in MSA. The findings of postmicturition residuals >100 ml, detrusor-external sphincter dyssynergia, open bladder neck at the start of bladder filling, and neurogenic sphincter motor unit potentials are highly suggestive of MSA.

Background: Micturitional disturbance is known to occur in subacute myelo-optico-neuropathy (SMON). However, its pathophysiology is uncertain and few data are available concerning urodynamic findings. We described our results of micturitional histories and urodynamic studies in patients with SMON. Methods: A history of urinary symptoms was obtained from six patients with SMON (two men, four women; age, 49–72 years, mean 60 years; duration of illness, 14–25 years, mean 19 years). All patients underwent urodynamic studies including measurement of post-micturition residuals, urethral pressure profilometry, cystometry and simultaneous sphincter electromyography. Results: All patients had micturitional symptoms including voiding symptoms in four, filling symptoms in four and urge urinary incontinence in a patient. Urodynamic studies revealed an increased maximum urethral closure pressure in two of four patients studied, decreased bladder volume at first sensation in two, detrusor hyperreflexia in three, absent bulbocavernosus reflex in a patient, and none had detrusor-sphincter dyssynergia or post-micturition residuals. Repeated urodynamic study (10 years after initial study) in a patient with detrusor hyperreflexia showed the same findings. Conclusion: Our results indicate that supranuclear pelvic nerve dysfunction to be mainly responsible for the micturitional disturbance in patients with SMON.

Urinary urgency and voiding difficulty are common features in neurological diseases, which can be attributed to dysfunction of the urethral sphincter and the detrusor. However, little is known about dynamic sphincter behaviour in neurological diseases. The present study aimed at investigating neurogenic failures of the external urethral sphincter closure and relaxation by videourodynamic study. We recruited 44 neurological patients with urinary urgency and frequency, 27 men and 17 women, mean age 61 years, and 28 of them had voiding difficulty as well. None had abnormal finding of digital examination or ultrasound echography of the pelvic organs. Using triple-lumen 7F catheter under X-ray fluoroscope, we measured detrusor pressure, external urethral sphincter pressure (Pura) and external sphincter EMG in all patients. We also performed pressure-flow study and obtained the Abram-Griffiths (AG) number, a numerical grade of obstruction. During filling 30 had detrusor hyperreflexia. EMG-cystometry showed uninhibited external sphincter relaxation (UESR) in eight patients, seven of whom had detrusor hyperreflexia as well. Patients with UESR showed an abnormal reduction of Pura, mean reduction 64 +/- 27 cmH2O (mean +/- standard deviation). During UESR the Pura and EMG activity fluctuated, and fluoroscopic image showed bladder neck opening in four with extreme urge sensation, including one without detrusor hyperreflexia. During an attempt of voiding three patients with voiding difficulty had detrusor-external sphincter dyssynergia (DESD) with detrusor contraction and eight had unrelaxing external sphincter without detrusor contraction. Fluoroscopic image showed an incomplete or absent urethral opening at the external sphincter. Four of them had severe straining on voiding together with intermittent increment of EMG activity without a normal funneling of the bladder neck. The mean reduction of Pura during voiding was 6.4 +/- 6.7 cmH2O and 5.0 +/- 9.5 cmH2O (in women and men, respectively) with DESD or unrelaxing external sphincter which was less than 39 +/- 25 cmH2O and 53 +/- 47 cmH2O in those without (P0.01). The mean AG number was 15 +/- 21 and 51 +/- 19 (for women and men, respectively) with DESD or unrelaxing external sphincter which was larger than 6.2 +/- 34 and 35 +/- 22 in those without (P0.05). In conclusion, UESR and DESD/unrelaxing external sphincter could be a factor for urinary urgency and voiding difficulty in neurological patients, evidence of central dysregulation affecting the Onuf's nucleus and its fibres to the external urethral sphincter.

Objectives. To perform a randomized comparative study investigating the urodynamic effects of functional magnetic stimulation (FMS) and functional electrical stimulation (FES) on the inhibition of detrusor overactivity. Methods. Thirty-two patients with urinary incontinence due to detrusor overactivity (15 men, 17 women; age 62.3 ± 16.6 years) were randomly assigned to two treatment groups (15 patients in the FMS group and 17 in the FES group). Stimulation was applied continuously at 10 Hz in both groups. For FMS, the magnetic stimulator unit was set on an armchair type seat and had a concave-shaped coil, so that the patients could sit during stimulation. For FES, a vaginal electrode was used in the women and a surface electrode on the dorsal part of the penis was used in the men. Cystometry was performed before and during the stimulation. Results. The bladder capacity at the first desire to void and the maximum cystometric capacity increased significantly during stimulation compared with prestimulation levels in both groups ( P = 0.0054 and 0.0026, respectively, in the FMS group and P = 0.0015 and 0.0229, respectively, in the FES group). However, the increase in the maximum cystometric capacity was significantly ( P = 0.0135) greater in the FMS group (114.2 ± 124.1 mL or an increase of 105.5% ± 130.4% compared with the pretreatment level) than that in the FES group (32.3 ± 56.6 mL or an increase of 16.3% ± 33.9%). Detrusor overactivity was abolished in 3 patients in the FMS group but not in any patient in the FES group. Conclusions. Although both treatments were effective, the inhibition of detrusor overactivity appeared greater in the FMS group than in the FES group.

Background: Micturitional disturbance is known to occur in neuro-Behcet’s syndrome (NBS). However, its pathophysiology is uncertain and few data are available concerning urodynamic findings. We describe our findings on micturitional histories and urodynamic studies in patients with NBS. Methods: A history of urinary symptoms was obtained from nine patients with NBS [seven male, two female, aged 26 to 54 years; mean, 41 years]. Neurological and CT/MRI findings indicated that their lesions were located mainly in the cerebral cortex, basal ganglia, cerebellum, brainstem and the spinal cord. Symptomatic patients underwent urodynamic studies, including measurement of post-micturition residuals, urethral pressure profilometry and EMG cystometry. Results: Six of the nine patients (67%) had urinary symptoms that included diurnal urinary frequency in five, sensation of urgency in five, urge urinary incontinence in five, voiding difficulty in five and nocturnal urinary frequency in four. None had urinary retention. Urodynamic studies performed in six patients showed post-micturition residuals in five (50–180 ml), increased maximum urethral closure pressure in two, decrease in four and increase in one of bladder capacities, detrusor hyperreflexia in five, decreased bladder sensation in one, brisk bulbocavernosus reflex in four, detrusor-sphincter dyssynergia in two and neurogenic sphincter EMG in one. Conclusion: Our results indicate that micturitional disturbance is not rare in patients with NBS. Supranuclear pelvic nerve dysfunction seems to be mainly responsible for the disturbance.

We report a case of neurosarcoidosis in which urodynamic studies showed neurogenic bladder dysfunction. A 30-year-old man began to have slowly progressive gait ataxia of vestibular origin, deafness, and hallucination, which developed into versive seizure and stupor. Brain computed tomography and magnetic resonance imaging showed the anteromedial frontal lobe lesion with mild ventricular enlargement. The cerebrospinal fluid examination revealed pleocytosis with raised total protein and angiotensin-converting enzyme levels. Endoscopic lung biopsy showed epithelioid granuloma. Oral prednislone (60 mg/day) ameliorated his symptoms. After tapering steroids, however, he developed urinary urgency, frequency, urge urinary incontinence, and a relapse of gait ataxia. The urodynamic study showed detrusor hyperreflexia. Prednisolone treatment again improved his urinary and neurological symptoms. The anteromedial frontal lobe lesion seems to be responsible for the micturitional disturbance in our patient with neurosarcoidosis. Neurourol. Urodynam. 19:273–277, 2000. © 2000 Wiley-Liss, Inc.

We obtained micturitional histories and performed urodynamic studies in six patients with pure autonomic failure. All patients had urinary symptoms. Urodynamic studies showed postmicturition residuals in two, small bladder capacities in two, detrusor hyperreflexia in four, low bladder compliance in two, detrusor-external sphincter dyssynergia in one, neurogenic sphincter electromyography in three, and denervation supersensitivity of the bladder in two. Micturitional disturbance is a common feature in pure autonomic failure because of peripheral and central types of abnormalities.

Sir,Brain MRI in patients with hepatic encephalopathy (HE)shows hyperintensity in the globus pallidus on T1-weightedimages, which is thought to reflect manganese andammonia accumulation in situ [1, 2]. Those patientscommonly have asterexis, disturbed consciousness, andextrapyramidal features [1, 2]. In contrast, ataxia in HE israre [3], and MRI correlates for ataxia have not beenentirely clear [4, 5]. We recently had a woman who, duringa course of HE, presented with bilateral, middle cerebellarpeduncle lesions and ataxia, both of which ameliorated afterbranched amino acid treatment.A 57-year-old woman suffered from primary biliarycirrhosis and hepatocellular carcinoma for the past 7 years.One year after the onset of diseases, she developedasterexis and disorientation to time and place. An intrave-nous administration of branched amino acid ameliorated hersymptoms. She was then started on kanamycin andlaxatives. However, 1 month before admission to ourhospital, an abdominal MRI revealed a recurrence ofhepatocellular carcinoma; in addition, she developedunsteadiness of the gait but without flapping tremor. Onadmission, she had slight disorientation to place. She hadcerebellar ataxia on finger to nose test, diadochokinesis,and heel-to-knee test. She had no extrapyramidal features orflapping tremor. Blood tests showed increased serum levelsof ammonia 183μg/dl (30–80) and total bilirubin 1.5 mg/dl(0.2–1.0). Brain MRI revealed high signal intensity in theglobus pallidus on T1-weighted image, and markedly highsignal intensity in the middle cerebellar peduncle bilaterally(Fig. 1a) and slightly high signal intensity in the cerebralwhite matter on T2-weighted image. We started her on anintravenous administration of 500 ml/day (valine 0.84%,leucine 1.10%, isoleucine 0.90%) intravenous branchedamino acid and low protein diet. Three weeks later, herataxia ameliorated significantly, and serum ammonia levelsdecreased to 113μg/dl. A post-treatment MRI scan, whichwas performed 1 month later, showed reduction inhyperintense signal (Fig. 1b).Previously, four reports of brain MRI imaging for ataxiain HE are available [4–7]. Park and Heo [4] reported a46-year-old man with acquired hepatocerebral degenerationwho developed ataxia and bilateral, middle cerebellarpeduncle lesions. In a review article, Uchino and colleagues[5] showed similar MRI findings. Nagura and colleagues[6] reported a 66-year-old man with portal-systemic shunt,with irreversible middle cerebellar peduncle involvement,attributed to hyperammonemia. Deguchi and colleagues [7]reported a 58-year-old woman with similar MRI findings,which improved by intravenous branched amino acids. Todate, no pathology studies are available accounting for theMRI abnormalities in the middle cerebellar peduncle.However, in cases of HE, demyelination has been demon-strated in the cerebral white matter [8], pontine base [9],and corticospinal tract [10]. Since myelinated axon is themain histological constituent in the cerebellar peduncle, theMRI findings in the middle cerebellar peduncle mightreflect demyelination. Since intravenous branched aminoacid soon ameliorated ataxia and the MRI lesions, togetherwith reversal of serum ammonia levels, cytotoxic edema

OBJECTIVES—Urinary dysfunction and orthostatic hypotension are the prominent autonomic features in multiple system atrophy (MSA). A detailed questionnaire was given and autonomic function tests were performed in 121 patients with MSA concerning both urinary and cardiovascular systems. METHODS—Replies to the questionnaire on autonomic symptoms were obtained from 121 patients including three clinical variants; olivopontocerebellar atrophy (OPCA) type in 48, striatonigral degeneration (SND) type in 17, and Shy-Drager type in 56. Urodynamic studies comprised measurement of postmicturition residuals, EMG cystometry, and bethanechol injection. Cardiovascular tests included head up tilt test, measurement of supine plasma noradrenaline (norepinephrine,NA), measurement of R-R variability (CV R-R), and intravenous infusions of NA and isoproterenol. RESULTS—Urinary symptoms (96%) were found to be more common than orthostatic symptoms (43%) (p

OBJECTIVES To investigate urinary function in the elderly with and without white matter lesion (leukoaraiosis) in relation to cognitive and gait function. METHODS Sixty three subjects were examined, with mean age 73 (range 62 to 86 years). Subjects with brainstem stroke or with large hemispheric lesions were excluded. Spin echo 1.5 T MRI images were graded from 0 to 4 for severity of white matter lesions. Urinary function was assessed by detailed questionnaire and urodynamic studies were performed in 33 of the subjects, including measurement of postmicturition residuals, water cystometry, and sphincter EMG. A mini mental state examination (MMSE) and examination of gait was also performed and compared with urinary function. RESULTS Urodynamic studies showed subjects with grade 1–4 white matter lesions to have detrusor hyperreflexia more commonly (82%) than those with grade 0 white matter lesions (9%) (p

Magnetic stimulation has been considered to be a technique for stimulating nervous system noninvasively and it has been used for experimental and clinical testings on the central and peripheral nervous systems. However, commercially available magnetic stimulators can only discharge single pulses for less than several minutes because the coil soon overheats. We newly devised a continuous magnetic stimulator assuring long-time stimulation, and this study was designed to confirm whether continuous magnetic stimulation would result in urethral closure and inhibition of bladder contraction in anesthetized canine models. Twelve female beagle dogs, weighing 9 to 12 kg, were anesthetized with a mixture of alpha-chloralose and urethane. In six beagles, a 4 F microtip transducer was inserted transurethrally, and maximum intraurethral pressure was monitored. In the remaining six animals, urethra was ligated at the bladder neck and a 4 F double lumen catheter was inserted from the dome of the bladder to infuse physiological saline, monitoring iso-volumetric rhythmic bladder contraction. The stimulating coil, of which temperature was kept at 20-25 degrees C by the built-in cooling system, was placed on the ishio-rectal fossa to stimulate the pudendal nerve at 10 Hz. The intraurethral pressure increased by 69.1 +/- 27.8 cm H(2)O, and iso-volumetric rhythmic bladder contraction was inhibited during the stimulation with 80% (240 Joule) of maximum output. In conclusion, continuous magnetic stimulator was found effective for urethral closure and inhibition of bladder contraction. Neurourol. Urodynam. 18:505-510, 1999.

Escherichia coli serotype O157:H7 causes serious food poisoning worldwide, especially in children and elderly people.1 It is also called verotoxin producing E coli (VTEC), which produces a cytotoxic Shiga-like toxin. Gastrointestinal, haemorrhagic, and uraemic effects are well known in VTEC infection,2 and neurological problems are likely to be more frequent than is generally recognised.3 Here we describe axonal polyneuropathy and encephalopathy in a young female patient associated with haemolytic-uraemic syndrome caused by VTEC infection. A 26 year old woman began to have abdominal pain and haemorrhagic diarrhoea. She was admitted to an emergency hospital and diagnosed as having haemorrhagic colitis due to probable food poisoning. Then her urinary volume gradually decreased and serum creatinine increased, and she was transferred to our hospital. On the 9th day she had a high fever of 39.7°C with increased C reactive protein of 7.6 mg/l and a leukocytosis of 17 800/mm3. She was in a state of anuria and her blood analysis showed severe kidney dysfunction (increased serum creatinine of 6.76 mg/l). She had severe anaemia (haemoglobin 6.0 g/dl), fragmentation, and tear drop deformation of red blood cells in the blood smear and increased lactate dehydrogenase …

Urinary retention is uncommon in patients with herpes zoster and anogenital herpes simplex. Seven patients (four men, three women) with a mean age of 68.1 years (range, 35-84) with urinary retention due to herpes zoster (n = 6) or anogenital herpes simplex (n = 1) were studied. Six patients had unilateral skin eruption in the saddle area (S2-4 dermatome) and one patient with herpes zoster had a skin lesion in the L4-5 dermatome. All patients had detrusor areflexia without bladder sensation, and two of them had inactive external sphincter on electromyography at presentation. Clean intermittent catheterization was performed, and voiding function was recovered in 4-6 weeks (average, 5.4) in all patients. Urodynamic study was repeated after recovery of micturition in three patients, and they returned to normal on cystometrography and external sphincter electromyography. Acute urinary retention associated with anogenital herpes infection has been thought to occur when the meninges or sacral spinal ganglia were involved, and, in conclusion, this condition may be considered to be reversible.

We report a case of adrenomyeloneuropathy (AMN) in which serial urodynamic studies showed neurogenic bladder dysfunction. The patient was in good health until the age of 12, when he began to lose his hair. At age 25 he started to have urinary urgency, difficulty in voiding, occasional fecal incontinence, erectile impotence, and progressive gait disturbance. In his first admission to our hospital age 31, he was intelligent but childish. He showed diffuse baldness, spastic paraparesis, and disturbed vibratory sensation. Serum cortisol response to corticotropin (ACTH) was low and serum levels of very long chain fatty acids were increased. Nerve conduction studies and sural nerve biopsy showed the presence of peripheral neuropathy. These findings confirmed the diagnosis of AMN. The first urodynamic study showed residual urine volume of 50 ml, impaired bladder sensation, and detrusor hyperreflexia. At age 38 he needed diapers because he became apathetic and demented, and could no longer stand by himself. MRI disclosed high signal intensities in the bilateral cerebral white matter. The second urodynamic study showed residual urine volume of 200 ml and decreased bladder capacity with marked detrusor hyperreflexia. Demyelinating lesions of the peripheral nerve and white matter of the spinal cord and the cerebrum may be mainly responsible for the micturitional disturbance in our patient with AMN. Neurourol. Urodynam. 17:207–212, 1998. © 1998 Wiley-Liss, Inc.

Micturitional disturbance is rarely mentioned in human herpetic brainstem encephalitis although the pontine tegmentum, called the pontine micturition centre, seems to regulate the lower urinary tract in experimental animals. The case of a 45 year old man, who developed subacute coma and hiccup-like dysrhythmic breathing, and needed assisted ventilation is reported. Examination of CSF showed mononuclear pleocytosis and antibody against herpes simplex virus type 1, but the opening pressure was 90 cm H2O. Brain CT showed brain swelling, predominantly in the posterior fossa, and bilateral subdural effusion. Herpetic brainstem encephalitis was diagnosed, and he received 900 mg/day vidarabine. On regaining consciousness, he had left trochlear nerve palsy, left corectopia, ageusia, and urinary retention. Brain MRI showed right side dominant, bilateral pontine segmental lesions extending slightly to the midbrain and medulla. After two weeks he was able to urinate but showed nocturnal urinary frequency, urinary incontinence, and voiding difficulty. Urodynamic studies showed a residual urine volume of 350 ml and detrusor hyporeflexia on voiding. Micturitional disturbance gradually disappeared together with the neurological signs. The bilateral pontine tegmental lesions in this patient are similar to those in previous findings on brainstem strokes, evidence of the presence of a pontine micturition centre in humans.

OBJECTIVES—To examine the frequency and pathophysiology of micturitional disturbance in patients with Guillain-Barre syndrome. METHODS—Micturitional symptoms were noted and neurological examinations made repeatedly during admission to hospital of patients with clinical and neurophysiologically definite Guillain-Barre syndrome. Urodynamic studies consisted of uroflowmetry, measurement of residual urine, urethral pressure profilometry, medium fill water cystometry, and external sphincter EMG. RESULTS—Seven of 28 (25%) patients with Guillain-Barre syndrome showed micturitional disturbance. The symptoms included voiding difficulty in six, urinary retention in three, nocturnal urinary frequency in three, and urge incontinence in two. These micturitional symptoms appeared after weakness occurred, and improved gradually along with the neurological signs. All three patients who showed retention became able to urinate. Urodynamic studies were made on four symptomatic patients two of whom underwent repeated study. Disturbed bladder sensation was noted in one patient, bladder areflexia in one, and absence of the bulbocavernosus reflex in one. Cystometry showed decreased bladder volume in two and bladder overactivity in two, one of whom had urge urinary incontinence and the other urinary retention. CONCLUSIONS—A quarter of the patients with Guillain-Barre syndrome tend to have micturitional disturbance. The patients studied had evacuation and storage disorders, as well as bladder areflexia and disturbed bladder sensation indicative of peripheral types of parasympathetic and somatic nerve dysfunction. Decreased bladder volume with bladder overactivity but no evidence of CNS involvement was also found, evidence that bladder overactivity also occurs in peripheral nerve lesions with probable pelvic nerve irritation.

A 30-year-old woman with Marfan's syndrome had chronic intractable headaches and spontaneous intracranial hypotension. The pain was concentrated over the occipitonuchal region, had elements of both migraine and tension headache, and was often aggravated by postural change. Myelography showed multiple, large, lumbosacral arachnoid diverticula. Radioisotope cisternography revealed a halolike accumulation in the lumbosacral region and rapid uptake of isotope in the urinary bladder, indicating cerebrospinal fluid leakage. Epidural blood patching brought immediate relief from the positional headaches. We concluded that patients with Marfan's syndrome and undifferentiated chronic headaches should be radiologically evaluated for spinal meningeal defects.

A 24-year-old pregnant woman started to have hyperemesis gravidarum 6 weeks before admission. Four weeks later she had vertigo, diplopia, staggering gait, mild dyspnea, dysphagia, and incontinence of urine. On admission she presented with ophthalmoplegia, ptosis, ataxia, decreased tendon reflex, and memory disturbance. Brain magnetic resonance imaging revealed abnormal intensities in medial thalamic-hypothalamic regions and the periaqueductal area, and she was diagnosed with Wernicke's encephalopathy. Urodynamic studies revealed decreased bladder volume and detrusor hyperreflexia. Six weeks after the administration of 100 mg/day of thiamine, urge incontinence gradually recovered, together with neurological signs. Lesions of the medial thalamic-hypothalamic area and the periaqueductal gray matter seemed to be mainly responsible for micturitional disturbance in our patient with Wernicke's encephalopathy.

Background Patients with Parkinson’s disease have higher risk of complications and revision surgery following spine surgery. Spinal fracture in an ankylosed spine is also difficult to treat. We recently treated a case of thoracic spine fracture in a patient with Parkinson’s disease complicating a severely ankylosed spine. There is no report describing surgical treatment of spine fracture in such a difficult condition, thus, we firstly report the case and discuss the reasons for a successful result. Case presentations A 68-year-old man with Parkinson’s disease had a pathologic thoracic spine fracture at T11. Four days after onset, he was referred to a local hospital because of gradually increasing back pain, but no spinal fracture was pointed out at that time. Because he developed lower extremity bilateral numbness and weakness, he was transported to our hospital, eight days after onset. When referred to our hospital, he exhibited severe back pain and paralysis of the lower extremities due to spinal cord involvement. Emergency surgery was performed. Decompression of T10-11 was performed followed by instrumented spinal fusion from T8 to L2. A dramatic neurological improvement was observed following surgery, and complete bony fusion was achieved. At the final two-year postoperative follow-up, the patient had no pathological symptoms related to spinal fracture and no instrument failure was observed. Conclusion This patient had Parkinson’s disease and a severely ankylosed spine, both of which may lead to unsatisfactory surgical results from spinal surgery. Generally, patients with Parkinson’s disease have an increased risk for adjacent segment disease and instrument failure. In this patient, fusion surgery did not change the number of fused segments because operated segments were already ankylosed. Because no stress force exists between adjacent vertebral bodies, a severely ankylosed spine may help prevent screw pullout. Thus, treatment of a spinal fracture in an ankylosed spinal segment is a less adverse condition for patients with Parkinson’s disease. Our experience led us to think that a combination of Parkinson’s disease with severely ankylosed spine does not necessarily suggest unsatisfactory outcomes after surgical treatment of spinal fracture.

Micturitional histories were taken from 39 patients with acute brainstem stroke. Within 3 months from onset, 49% had irritative as well as obstructive urinary symptoms, the most common being voiding difficulty and nocturnal urinary frequency in 28%, followed by urinary retention in 21%. Urodynamic studies of 11 symptomatic patients revealed detrusor hyperreflexia in 73%, low compliance bladder in 9%, atonic cystometrogram in 27%, detrusor-sphincter dyssynergia in 45% and uninhibited sphincter relaxation in 27%. Three asymptomatic patients had normal urodynamic findings. Brain magnetic resonance images of the lesions of the symptomatic patients were concentrated in the dorsolateral pons including pontine reticular nucleus and the reticular formation adjacent to the medial parabrachial nucleus and the locus coeruleus. These regions seem to be mainly responsible for supranuclear types of pelvic and pudendal nerve dysfunction in our patients with brainstem stroke, corresponding to the pontine urinary storage and micturation center reported in animal studies.

Micturitional histories and urodynamic studies were performed in 72 acute hemispheric stroke patients. Within 3 months from the onset, 53% of the patients had urinary symptoms including irritative as well as obstructive, and the most common symptom was nocturnal urinary frequency in 36%, which was followed by urge urinary incontinence in 29% and difficulty of voiding in 25% of the patients. We found a correlation between micturitional disturbance with hemiparesis (p

Micturitional disturbance has attracted little attention in myotonic dystrophy, but detailed micturitional histories revealed that two out of six patients (33%) had micturitional symptoms. One had difficulty urinating and the other had urinary frequency, urgency and stress incontinence. Urodynamic studies were performed in all patients and the results were as follows: Two had low maximum urethral closure pressure, two had large and three had small bladder capacities, one had detrusor hyperreflexia and one had atonic cystometrogram. Urethral sphincter electromyography revealed a decreased bulbocavernosus reflex in one, and an absent anal reflex in two. Motor unit analysis of external sphincter was performed with one patient and showed polyphasic potentials. Dystrophic changes of the lower urinary tract muscles, as well as supranuclear type of pelvic nerve dysfunction, could cause micturitional disturbance in patients with myotonic dystrophy.

We reported the findings of micturitional histories and urodynamic studies in five patients with human T-lymphotropic virus type-1-associated myelopathy. Histories showed that all patients had obstructive as well as irritative micturitional symptoms, and four of their micturitional symptoms appeared from the onset of the disease. Urodynamic studies showed that four of them had residual urine (average 170 ml), all had detrusor hyperreflexia, two had detrusor-sphincter dyssynergia, and none had neurogenic changes in external urethral sphincter electromyography. Our findings of supranuclear type of voiding dysfunctions seemed to be in accordance with the known pathological lesions of this disease.

We assessed the effect of a new alpha-blocking agent, Urapidil, on neuropathic voiding dysfunction, by urodynamic studies. The residual urine volume and rate significantly decreased, whereas the average and the maximum flow rate did not increase significantly. The pressure at maximum flow and minimum urethral resistance decreased significantly. These results suggest that improvement of the voiding dysfunction in some cases could be due to the decreased micturition pressure without increasing the flow rate. The urethral resistance calculated from the pressure/flow data seemed to be a valuable index in evaluating the effects of the drug on neuropathic voiding dysfunction.

The effects of beta 2-stimulants [clenbuterol (CB) and terbutaline (TB)] on the contractility of the urethral sphincter of female dogs were studied by measuring intraurethral pressure (IUP) during stimulation of bilateral pudendal nerves. In nine dogs 1, 10 and 100 micrograms/kg. of CB were administered, but no changes in IUP were observed. In the other 33 dogs, sphincteric fatigue was experimentally prepared by electrically stimulating the pudendal nerves at 15 V, 20 Hz for 30 to 40 minutes. In fatigued sphincters, CB (n = 17) and TB (n = 7) increased the contracting pressure (pressure difference between stimulation-generated peak level and baseline level of IUP). The inotropic effect of beta 2-stimulant (TB) on the fatigued urethral sphincter was abolished by a beta-blocker, propranolol. From the present study it was concluded that beta 2-stimulants have little effect on the total contractility of the nonfatigued urethral sphincter because it is composed of smooth and striated muscles (fast- and slow-contracting muscles). However, beta 2-stimulants enhanced the contractility of fatigued urethral sphincter. These results suggest that beta 2-stimulants act on fast-contracting fibers in the urethral sphincter because the inotropic effect of sympathomimetic amine is much greater on fatigued, fast-contracting fibers than on nonfatigued ones and its depressive effect on slow-contracting fibers is not potentiated after fatigue.

Summary: Detailed micturitional histories and urodynamic studies were performed in five patients with radiation myelopathy. All patients had micturitional symptoms that were irritative in five and obstructive in four, and four had urinary incontinence. Urodynamic studies showed that three patients had residual urine of 158 ml on average. Cystometry showed that four patients had detrusor hyperreflexia and one had low compliance cystmetrogram. External sphincter electromyography showed that four patients had detrusor-sphincter dyssynergia. These results indicated that micturitional disturbance seemed to be common and severe in storage as well as evacuation function. The main responsible sites of lesions seemed to be supranuclear parasympathetic and somatic nervous systems regulating the lower urinary tract. Two of three patients who underwent combination of steroid pulse therapy and hyperbaric oxygen therapy experienced improvement of micturitional disturbance and other neurological deficits.

A 58-year-old Japanese patient was referred to our departments with 1 week history of severe constipation together with a painful skin eruption in his left abdomen. He had abdominal distension, pain, anorexia, and no bowel movements for 1 week at all. A plain abdominal x-ray revealed colonic dilatation but haustra only in the proximal colon (figure 1). Abdominal CT and ultrasound echography revealed no evidence of colonic spasm or obstruction. His blood tests, including C-reactive protein, were normal. Neurological examination revealed no evidences of myelopathy …