前島 伸一郎

Background: Robotic devices are expected to be widely used in various applications including support for the independent mobility of the elderly with muscle weakness and people with impaired motor function as well as support for nursing care that involves heavy laborious work. We evaluated the effects of a hybrid assistive limb robot suit on the gait of stroke patients undergoing rehabilitation. Methods: The study group comprised 16 stroke patients with severe hemiplegia. All patients underwent gait training. Four patients required assistance, and 12 needed supervision while walking. The stride length, walking speed and physiological cost index on wearing the hybrid assistive limb suit and a knee-ankle-foot orthosis were compared. Results: The hybrid assistive limb suit increased the stride length and walking speed in 4 of 16 patients. The patients whose walking speed decreased on wearing the hybrid assistive limb suit either had not received sufficient gait training or had an established gait pattern with a knee-ankle-foot orthosis using a quad cane. The physiological cost index increased after wearing the hybrid assistive limb suit in 12 patients, but removal of the suit led to a decrease in the physiological cost index values to equivalent levels prior to the use of the suit. Conclusions: Although the hybrid assistive limb suit is not useful for all hemiplegic patients, it may increase the walking speed and affect the walking ability. Further investigation would clarify its indication for the possibility of gait training.

We report a patient with unilateral midbrain hemorrhage which caused ipsilateral complete oculomotor nerve palsy with pupillary involvement, contralateral upgaze paresis, contralateral limb ataxia and Parinaud's syndrome. CT scan and MRI brain demonstrated a hemorrhage in the left paramedian midbrain probably involving the oculomotor fascicles; extension of the hemorrhage to the most rostral midbrain may have involved the pupillary fibers. It was previously thought that a lesion in the superior colliculus, surrounding nuclei (Darkschewitsch and Cajal nuclei), and the posterior commissure (i.e. dorsal midbrain) were responsible for clinical findings similar to those found in our patient, but our patient showed a hemorrhagic lesion in the left ventral midbrain which did not extend to dorsal midbrain. We propose that the responsible lesion in our patient might involve the rostral interstitial nucleus of the medial longitudinal fasciculus (riMLF).

Maeshima S, Osawa A, Miyazaki Y, Seki Y, Miura C, Tazawa Y, Tanahashi N: Influence of dysphagia on short-term outcome in patients with acute stroke. Am J Phys Med Rehabil 2011; 90: 316-320. Objective: The aim of this study was to determine whether dysphagia present at initial swallowing evaluation is associated with the type of diet eaten at the time of discharge and the location to which the patient is transferred after discharge. Design: A total of 409 newly diagnosed acute stroke patients were studied. Results: After hospital discharge, 140 patients returned home, 250 were transferred to another hospital for rehabilitation, and 7 were admitted to a nursing home. Twelve patients died. A total of 205 patients were on a regular diet, 96 were receiving a dysphagia diet, and 96 were on enteral feeding at discharge. A total of 90.7% (127/140) of patients who were discharged home were on a regular diet. Most of the patients on a dysphagia diet or enteral feeding could not return home. The scores of the functional independence measure were higher in the patients who returned to their homes than in other groups. Conclusions: Although it is necessary to indicate other factors, such as the physical status to establish better rehabilitation networks, clinical assessment of swallowing in acute stroke is very important to determine whether the patients

Pure alexia is severe difficulty in reading and understanding written language but with normal oral language and writing abilities. We report a patient with pure alexia caused by two different infarct lesions in the left lateral thalamus and the left splenium of the corpus callosum. A 56-year-old right-handed man was admitted to hospital with right homonymous hemianopia associated with pure alexia. He could write kana characters but not kanji. His cranial magnetic resonance imaging revealed two different infarct lesions in the left optic radiation and the left splenium of the corpus callosum. Magnetic resonance angiography showed mild stenosis at the origin of the right vertebral artery and stenosis of the left distal posterior cerebral artery. The mechanism of developing pure alexia can be simply explained by disconnection. We assumed that agraphia of kanji was caused by the effect of ischemia and edema following transient obstruction in branches from the distal posterior cerebral artery.

わが国における高次脳機能障害者に対する診療の広がりについて調査した。第1次調査は、高次脳機能障害者の有無、サービス内容などの基本的な情報を多くの施設から得ることとした。9割を超える施設に高次脳機能障害者がおり、認知症、失語症、半側空間無視などが多かった。失語症に対する言語訓練は過半数の施設で行われていたが、神経心理学的評価および認知リハビリテーションを行っている施設は半数に満たなかった。第2次調査は、各種の高次脳機能障害の種類別に施設の組織・規模、症例数、サービス内容、職種、言語・認知リハビリテーション、社会福祉制度の利用および社会復帰について調査した。失語症がもっとも多く、認知症、記憶障害などが続いた。失語症の言語治療とともに失語症以外の高次脳機能障害に対する認知リハビリテーションは広く行われていたが、就労支援、心理療法は十分普及していなかった。就労率は全般に不良であった。

A 54-year-old, right-handed male suffered sudden onset of vertigo and vomiting. He was diagnosed with brainstem hemorrhage, and treatment was administered. After the vertigo improved, he showed disturbance of attention and anterograde amnesia. Magnetic resonance imaging revealed a hematoma across the pons on both sides, but no lesions were obvious in the cerebellum or the cerebrum. Single photon emission tomography showed decreased perfusion not only in the brainstem but also in the bilateral frontal and temporal lobes. Amnesia and executive dysfunction decreased in the 8 months following the stroke onset, with improvement in regional cerebral blood flow to the frontal and temporal lobes. These findings suggest that a hemorrhage in the pons caused diaschisis resulting in a secondary reduction of activity in the cerebral cortex and the occurrence of cortical symptoms.

急性期病院における脳卒中リハビリテーション(リハ)に携わる立場から，地域連携パスを用いて回復期リハ病院へ転院した脳卒中患者240名を対象に，その回収状況や記載不備を調査するとともに，転院時の身体機能・認知機能，回復期リハ病院での改善状況と転帰などについて調査した．その結果，204名(85.0%)の地域連携パスが回収されたが，急性期病院で46件(22.5%)，回復期病院で34件(16.2%)の地域連携パスに記載不備を認めた．回復期リハ病院へ転院までの期間は29.5 ± 14.2日，回復期リハ病院での平均在院日数は101.1 ± 57.0日で，退院後の転帰は，自宅145名(74.5%)，療養型病棟13名(6.8%)，介護施設29名(15.1%)，その他7名(3.6%)であった．回復期病棟での平均在院日数ならびにADLの改善は，転出した回復期リハ病院間で明らかな違いがみられた．以上より，地域連携パスを用いた全ての医療機関で，データの蓄積や解析などに関する共通の認識が必要であり，急性期病院のリハに携わるものが，連携パスを通じて，積極的にリハの質的向上に関与していく必要がある．

症例は62歳男性で、30年前より糖尿病を指摘されたが未治療で経過した。1年前よりインスリンを導入し、高血圧、急性心筋梗塞に対し経皮的冠動脈血管形成術を施行され、2枝病変に対しステントを留置された。3年前より記銘力低下を認め1年前よりメモ帳にに記載しないと忘れるようになった。3ヵ月前、右手脱力、右手の感覚異常を認めた。下肢の閉塞性動脈症の精査中に無名動脈の狭窄を指摘され受診した。意識清明で視力、視野、眼球運動に異常を認めず、脳神経系にも異常なかった。右手の軽度な筋力低下と感覚低下を認めた。高次脳機能障害で発症し、盗血現象を主体とする血行動態を呈した無名動脈狭窄症の1例で経皮的血管形成術が有用であった。

回復期リハビリテーション(リハ)病棟から在宅復帰が可能であった重症脳卒中患者の特徴を捉え，どのような要因が在宅復帰を可能にするかを明らかにすることを目的とした．対象は初回発症の脳卒中で日常生活が重度に障害されている患者で，運動麻痺，認知機能，日常生活活動(ADL)，同居家族数を調査し，在宅復帰群と施設・転院群の2群に分けて比較した．入院時の運動麻痺やADLは両群間で差を認めなかったが，認知機能，同居家族数は両群間で差を認めた．また，入院後1週間毎のADLおよび退院時のADLは両群間で差を認めた．以上より，入院時の認知機能と同居家族を評価し，入院1週間後のADLの変化を確認した上で，家族に十分な機能予後と対応策を説明し，ゴール設定を行うことが，効率の良い医療を進めていくためにも大切である．

症候性てんかん(poststroke epilepsy：PSE)により重積状態を呈した陳旧性脳梗塞患者の嚥下機能に着目し，臨床的検討を行った．対象はPSEの発症前には経口摂取が可能であった15名で，脳梗塞の最終発症から痙攣発作までの期間は4～108カ月であった．重積後のPSEでは嚥下障害を15名中10名に認めた．全身状態が不良で，経鼻経管栄養のまま転院となった1名を除き，嚥下障害がみられなかった4名はPSE前と同様の摂食が可能となり，自宅退院となった．しかし，嚥下障害を呈した患者の多くは入院中にPSE前と同様の摂食が困難で転院となった．経口摂取が可能な脳梗塞患者であってもPSEを契機に嚥下障害が明らかとなる場合があり，積極的な嚥下機能の評価と慎重な対応が必要であると思われた．

内頸動脈狭窄症に対して，Auditory Verbal Learning Test(AVLT)を施行し，内頸動脈の病変側や合併する大脳白質病変の重症度，その他の神経心理学的検査との関連について検討した．対象は一過性脳虚血性発作や軽症脳梗塞で診断に至った症候性の内頸動脈狭窄症44名で，AVLTに加え，Mini-mental State Examination，Raven's coloured progressive matrices，Frontal Assessment Batteryなどの神経心理学的検査を施行した．その結果，短期記憶，全即時記憶，言語学習能力，逆行性干渉など，AVLTのいずれの指標も病変側で差を認めなかった．また，側脳室周囲病変や深部皮質下白質病変の重症度が高いほどAVLTの成績は低下し，学習曲線は平坦化する傾向にあった．AVLTの成績はその他の神経心理学的検査の成績と正の相関を認めた．以上より，AVLTは，大脳白質病変を合併した内頸動脈狭窄症患者に関して，認知機能の低下をよく反映しており，高次脳機能スクリーニング検査の一つとして有用であることが示唆された．