Hikaru Muramatsu’s research while affiliated with Kasugai Municipal Hospital and other places

We evaluated quantitatively the recovery from impairment and disability in hemiplegic stroke survivors who received cranioplasty in the chronic stage. Seven first-ever stroke survivors with hemiplegia (mean age 56+/-3 years) who required delayed (3-9 months after the onset) cranioplasty during continuous rehabilitation therapy were studied. Recovery grade (1-12) of hemiplegia and Barthel index were assessed monthly before (the first rehabilitation) and after the cranioplasty (the second rehabilitation). The recovery grade of upper and lower extremity movements significantly increased both in the first and in the second rehabilitation. Changes in the upper and lower extremity grades were significantly larger in the second rehabilitation (1.0+/-0.3 in the first vs. 2.4+/-0.7 in the second rehabilitation for upper extremity, P=0.007; 1.4+/-0.4 in the first vs. 3.4+/-0.7 in the second rehabilitation for lower extremity, P=0.002). Increase in the Barthel index was larger in the second rehabilitation (23+/-8 in the first vs. 33+/-5 in the second rehabilitation); all patients regained the ability to walk. Significant recovery of functional grade and recovery from disability occurred after the cranioplasty in the chronic stage (>or=3 months) of stroke.

This study presents two adult patients who experienced pleural effusion during hospitalization for stroke rehabilitation therapy after ventriculoperitoneal shunt placement for normal pressure hydrocephalus associated with aneurysmal subarachnoid haemorrhage. The pleural effusion appeared without migration of the catheter into the thoracic cavity. Because of respiratory insufficiency, which prevented progress in their rehabilitation programme, thoracentesis was repeated for recurrent pleural effusions, the composition of which differed significantly from that of cerebrospinal fluid. Both cases had past histories of laparostomies; therefore, the distal end of the catheter was placed in the right anterior subphrenic recess. One was able to resolve the pleural effusion and rehabilitate the patients by replacing the ventriculoperitoneal shunt with a vetriculoatrial shunt. In the literature, there have been only 23 reports of pleural effusion associated with a ventriculoperitoneal shunt. Among those reports, four involved pleural effusion without migration of the distal catheter; however, all of those cases were in children. Thus, this study reports the first adult cases of pleural effusion without migration of the catheter into the pleural cavity and discusses a putative mechanism.

A 65-year-old man was implanted with an artificial pacemaker for chronic bradycardic atrial fibrillation associated with hypertensive heart disease. Five years after the pacemaker implantation, he suffered from a cerebral embolism. Approximately 4.5 months after the ictus, he was transferred to the rehabilitation ward. He had flaccid left hemiplegia and severe disuse syndrome. He could not sit and could tilt his head up for only two minutes because of severe orthostatic hypotension. By modulating the rate-responsive mode of the pacemaker every 2-4 weeks, we were able to rehabilitate the patient. Thus, the patient could sit in a wheelchair for more than three hours. This case emphasizes the importance of examining the mode and function of a previously implanted artificial pacemaker. In accord with varying rehabilitation programs and gradual improvement in a patient's physical activities, periodic modulation of a programmable pacemaker can lead to a better functional outcome during rehabilitation therapy.

Setting: Inpatient stroke rehabilitation hospital. Patient: A 60-year-old man with an artificial pacemaker suffered from cardiogenic cerebral embolism. Case Description: The patient received a pacemaker (ventricular demand inhibited pacemaker with rate-adaptive mode) implantation for chronic bradycardic atrial fibrillation. The pacemaker relieved his congestive heart failure and episodes of Adams-Stokes syndrome. 5 years after the implantation, he suffered a hemorrhagic cerebral embolism, which led to severe disability. He had flaccid left hemiplegia and severe disuse syndrome after prolonged (>4mo) bedrest. He could not sit up and could tilt his head up for less than 2 minutes because of mortal orthostatic intolerance and hypotension and a lack of physiologic Bainbridge reflex. Low endurance of exercise with absolute chronotropic incompetence arrested the rehabilitation. By modulating programmable pacemaker function every 2 weeks, we started to rehabilitate the patient. The programmable function was an optimal or lower rate and a rate-adaptive pacing rate, which included upper sensor rate, activity threshold, reaction time, and recovery time, in response to physical motion and activity. Assessment/Results: Periodic programming of the pacemaker function allowed him to continue rehabilitation. Specifically, we enabled its ability to vary the pacing rate in response to increased physical activity in accordance with progressive rehabilitation programs. After 4 months of rehabilitation, he could sit in a wheelchair for >3 hours without significant orthostatic hypotension and he performed activities of daily living with mild assistance. Discussion: This case emphasizes the importance of examining the function of a previously implanted pacemaker. In accord with varying rehabilitation programs and gradual improvement in physical activities, periodic adjustment of a programmable pacemaker can lead to a better functional outcome. Conclusion: Rate-adaptive pacemaker mode benefited this stroke patient, who had severe orthostatic intolerance and chronotropic incompetence, that is, flaccid hemiplegia and bradycardic atrial fibrillation.

We examined the prevalence of shunt dysfunction (e.g., overdraining or underdraining malfunctions) in patients with a ventriculoperitoneal shunt and elucidated effective countermeasures of a programmable valve shunt system in treatments for shunt dysfunction during rehabilitation therapy. Among 114 patients with a ventriculoperitoneal shunt for normal pressure hydrocephalus, underdraining appeared in eight patients during hospitalization for rehabilitation therapy, and seven patients experienced overdraining. We could treat underdraining noninvasively for all six patients with a programmable valve shunt system by decreasing the opening pressure, whereas the other two patients with a fixed valve pressure system required surgical replacement of the valve unit. We could also treat overdraining noninvasively in two cases with programmable valve shunt system by increasing the opening pressure. In two cases with fixed valve pressure system, however, chronic subdural hematomas had to be surgically treated. Either dysfunction interfered with a better functional outcome in rehabilitation therapy. Barthel index after the countermeasures and continuous rehabilitation therapies was significantly larger than the index before the countermeasures in both overdraining and underdraining groups. Shunt dysfunction appeared in approximately 13.2% of patients with a ventriculoperitoneal shunt during hospitalization for rehabilitation. The ventriculoperitoneal shunt using programmable valve shunt system was convenient and valuable for treating both overdraining and underdraining malfunctions in the rehabilitation ward.

Muramatsu H, Koike K, Teramoto A: Ventriculoperitoneal shunt dysfunction during rehabilitation: Prevalence and countermeasures. Am J Phys Med Rehabil 2002;81:571–578. Objective: We examined the prevalence of shunt dysfunction (e.g., overdraining or underdraining malfunctions) in patients with a ventriculoperitoneal shunt and elucidated effective countermeasures of a programmable valve shunt system in treatments for shunt dysfunction during rehabilitation therapy. Subjects: Among 114 patients with a ventriculoperitoneal shunt for normal pressure hydrocephalus, underdraining appeared in eight patients during hospitalization for rehabilitation therapy, and seven patients experienced overdraining. Results: We could treat underdraining noninvasively for all six patients with a programmable valve shunt system by decreasing the opening pressure, whereas the other two patients with a fixed valve pressure system required surgical replacement of the valve unit. We could also treat overdraining noninvasively in two cases with programmable valve shunt system by increasing the opening pressure. In two cases with fixed valve pressure system, however, chronic subdural hematomas had to be surgically treated. Either dysfunction interfered with a better functional outcome in rehabilitation therapy. Barthel index after the countermeasures and continuous rehabilitation therapies was significantly larger than the index before the countermeasures in both overdraining and underdraining groups. Conclusions: Shunt dysfunction appeared in approximately 13.2% of patients with a ventriculoperitoneal shunt during hospitalization for rehabilitation. The ventriculoperitoneal shunt using programmable valve shunt system was convenient and valuable for treating both overdraining and underdraining malfunctions in the rehabilitation ward.

Objective: We evaluated quantitatively the further recovery from impairment and disability in the hemiplegic stroke survivors who required neurosurgical intervention, i.e. cranioplasty or ventriculoperitoneal (V-P) shunt, in chronic stage. Setting: Rehabilitation (RH) ward affiliated with university hospitals. Patients: Eleven first-ever stroke patients with hemiplegia (mean age, 56.3+/-2.5 years) out of 498 survivors required delayed (between 4 and 10 months after the onset) neurosurgical intervention during continuous RH therapy. Six patients received cranioplasty for preexisting hemicraniectomy, and five required V-P shunt for normal pressure hydrocephalus with later complications. Main outcome measures: Recovery grade (1--12) of hemiplegia and Barthel index were assessed monthly before (the 1st RH) and after the intervention (the 2nd RH). Results: The recovery grade of upper and lower extremity movements significantly increased both in the 1st and 2nd RH. Changes in the upper and lower extremity grades were significantly larger in the 2nd RH (0.5+/-0.3 in the 1st vs. 2.5+/-0.6 in the 2nd RH for upper extremity, p<0.005; 0.9+/-0.3 in the 1st vs. 3.4+/-0.5 in the 2nd RH for lower extremity, p<0.001). Barthel index increased significantly only in the 2nd RH (from 48+/-7 to 90+/-3, p<0.001); all patients regained the ability to walk independently. Conclusions: Significant recovery of functional grade and recovery from disability occurred after the neurosurgical intervention in the chronic stage (geq 4 months) of stroke.