Background and Purpose-About one half of those who develop adult-onset moyamoya disease experience intracranial hemorrhage. Despite the extremely high frequency of rebleeding attacks and poor prognosis, measures to prevent rebleeding have not been established. The purpose of this study is to determine whether extracranial-intracranial bypass can reduce incidence of rebleeding and improve patient prognosis. Methods-This study was a multicentered, prospective, randomized, controlled trial conducted by 22 institutes in Japan.Adult patients with moyamoya disease who had experienced intracranial hemorrhage within the preceding year were given either conservative care or bilateral extracranial-intracranial direct bypass and were observed for 5 years. Primary and secondary end points were defined as all adverse events and rebleeding attacks, respectively. Results-Eighty patients were enrolled (surgical, 42; nonsurgical, 38). Adverse events causing significant morbidity were observed in 6 patients in the surgical group (14.3%) and 13 patients in the nonsurgical group (34.2%). Kaplan-Meier survival analysis revealed significant differences between the 2 groups (3.2%/y versus 8.2%/y; P=0.048). The hazard ratio of the surgical group calculated by Cox regression analysis was 0.391 (95% confidence interval, 0.148-1.029).Rebleeding attacks were observed in 5 patients in the surgical group (11.9%) and 12 in the nonsurgical group (31.6%), significantly different in the Kaplan-Meier survival analysis (2.7%/y versus 7.6%/y; P=0.042). The hazard ratio of the surgical group was 0.355 (95% confidence interval, 0.125-1.009). Conclusions-Although statistically marginal, Kaplan-Meier analysis revealed the significant difference between surgical and nonsurgical group, suggesting the preventive effect of direct bypass against rebleeding. Clinical Trial Registration

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Knowledge of how changes in bladder volume and the urge to void affect brain activity is important for understanding brain mechanisms that control urinary continence and micturition. This study used PET to evaluate brain activity associated with different levels of passive bladder filling and the urge to void. Eleven healthy male subjects (three left- and eight right-handed) aged 19-54 years were catheterized and the bladder filled retrogradely per urethra. Twelve PET scans were obtained during two repetitions of each of six bladder volumes, with the subjects rating their perception of urge to void prior to and after each scan. Increased brain activity related to increasing bladder volume was seen in the periaqueductal grey matter (PAG), in the midline pons, in the mid-cingulate cortex and bilaterally in the frontal lobe area. Increased brain activity relating to decreased urge to void was seen in a different portion of the cingulate cortex, in premotor cortex and in the hypothalamus. Both activation patterns were predominantly bilaterally symmetric and none of the effects could be attributed to the presence of the catheter. However, in some subjects, mostly those reporting intrusive sensations from the urethral catheter, there was a discrepancy between filling volume and urge so that they reported high urge with low volumes. As this 'mismatch' decreased, activation increased bilaterally in the somatosensory cortex. Our findings support the hypothesis that the PAG receives information about bladder fullness and relays this information to areas involved in the control of bladder storage. Our results also show that the network of brain regions involved in modulating the perception of the urge to void is distinct from that associated with the appreciation of bladder fullness.

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Objectives-Urinary dysfunction is a prominent autonomic feature in Parkinson's 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 oVer 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 diVerential 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-GriYths 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, detrusorexternal sphincter dyssynergia, open bladder neck at the start of bladder filling, and neurogenic sphincter motor unit potentials are highly suggestive of MSA. (J Neurol Neurosurg Psychiatry 2001;71:600-606)

A consensus-based Terminology Report for ANLUTD has been produced to aid clinical practice and research.

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<0.05), indicating that leukoaraiosis was a factor associated with geriatric urinary dysfunction. Postmicturition residuals, low compliance, detrusor-sphincter dyssynergia, and uninhibited sphincter relaxation were also more common in grade 1-4 than in grade 0 white matter lesions, though the diVerence was not significant. In grade 1 white matter lesions urinary dysfunction (urge urinary incontinence) was more common than cognitive (MMSE<19) (p<0.05) and gait disorders (slowness, short step/festination, and loss of postural reflex) (p<0.05), which increased together with the grade of white matter lesions (p<0.05). Conclusions-Urinary dysfunction is common and probably the early sign in elderly people with leukoaraiosis on MRI. (J Neurol Neurosurg Psychiatry 1999;67:658-660) Keywords: geriatric urinary incontinence; leukoaraiosis; autonomic dysfunction; urodynamic study; detrusor hyperreflexia The definite cause of high incidence of nocturnal urinary frequency and urge incontinence in elderly people is not known.1 Sleep disorder, nocturnal polyuria, and benign outlet obstruction of the lower urinary tract are possibly related to this condition. Detrusor hyperreflexia is a recognised finding in urodynamic study, which indicates central aetiology of this condition as well. 2 3 Brain MRI showed frequent white matter signal abnormality (leukoaraiosis) in the brain of elderly people, 4 some of which were considered as normal but others reflected ischaemic pathology.5 6 Leukoaraiosis in elderly people is relevant to cognitive disorder (multiinfarct dementia) 7 8 and gait disorder. 9 However, urinary dysfunction has not been systematically investigated. The present study aimed at evaluating urinary function in elderly people with and without leukoaraiosis in relation to cognitive and gait function. Subjects and methodsWe investigated 63 subjects, 28 men and 35 women, mean age 73 years, range 62-86 years.

Parkinson's disease (PD) is a common neurodegenerative disorder, and lower urinary tract (LUT) dysfunction is one of the most common autonomic disorders with an estimated incidence rate of 27-80%. Studies have shown that bladder dysfunction significantly influences quality-of-life (QOL) measures, early institutionalisation, and health economics. We review the pathophysiology of bladder dysfunction in PD, lower urinary tract symptoms (LUTS), objective assessment, and treatment options. In patients with PD, disruption of the dopamine D1-GABAergic direct pathway may lead to LUTS. Overactive bladder (OAB) is the most common LUT symptom in PD patients, and an objective assessment using urodynamics commonly shows detrusor overactivity (DO) in these patients. The post-void residual (PVR) volume is minimal in PD, which differs significantly from multiple system atrophy (MSA) patients who have a more progressive disease that leads to urinary retention. However, subclinical detrusor weakness during voiding may also occur in PD. Regarding bladder management, there are no large, double-blind, prospective studies in this area. It is well recognised that dopaminergic drugs can improve or worsen LUTS in PD patients. Therefore, an add-on therapy with anticholinergics is required. Beta-3 adrenergic agonists are a potential treatment option because there are little to no central cognitive events. Newer interventions, such as deep brain stimulation (DBS), are expected to improve bladder dysfunction in PD. Botulinum toxin injections can be used to treat intractable urinary incontinence in PD. Transurethral resection of the prostate gland (TURP) for comorbid BPH in PD is now recognised to be not contraindicated if MSA is excluded. Collaboration of urologists with neurologists is highly recommended to maximise a patients' bladder-associated QOL. Neurourol. Urodynam. 35:551-563, 2016. © 2015 Wiley Periodicals, Inc.