Rationale:We report on a stroke patient who showed change of the ascending reticular activating system (ARAS) concurrent with recovery from a vegetative state (VS) to a minimally conscious state (MCS), which was demonstrated on diffusion tensor tractography (DTT).Patient concerns:A 59-year-old male patient underwent CT-guided stereotactic drainage 3 times for management of intracerebral hemorrhage and intraventricular hemorrhage.Diagnosis:After 4 months from onset, when starting rehabilitation, the patient showed impaired consciousness, with a Glasgow Coma Scale (GCS) score of 6 and a Coma Recovery Scale-Revised score of 2. At 10 months after onset, his GCS score had recovered to 11 with a GRS-R score of 20, and he was able to perform rock–scissors–paper using his right hand according to verbal command.Interventions:On 10-month DTT, marked increased neural connectivity of the thalamic intralaminar nucleus (ILN) to the cerebral cortex was observed in both prefrontal cortexes and the right thalamus compared with 4-month DTT. However, no significant change was observed in the lower dorsal ARAS between the pontine reticular formation (PRF) and the thalamic ILN. In addition, the reconstructed lower ventral ARAS between the PRF and hypothalamus had disappeared in both hemispheres on 10-month DTT.Outcomes:Change of the ARAS was demonstrated in a stroke patient who showed recovery from a VS to an MCS.Lessons:It appeared that the prefrontal cortex and thalamus, which showed increased neural connectivity, contributed to recovery from a VS to an MCS in this patient.

Rationale: Limb-kinetic apraxia (LKA) is a disorder of movement execution that is a result of injury to the corticofugal tracts (CFTs) from the secondary motor area. We report on a patient with traumatic brain injury (TBI) and complete monoplegia due to LKA, which was mainly ascribed to injury of the CFT from the secondary motor area using diffusion tensor tractography. Patient concerns: A 35-year-old male was struck by a car from the side during riding an autocycle and received direct head trauma as a result of falling to ground. He lost consciousness for approximately 1 month and experienced continuous post-traumatic amnesia after the accident. The patient's Glasgow Coma Scale score was 3 and he showed quadriparesis including complete monoplegia of his left arm since the onset of TBI. Diagnoses: The patient diagnosed complete monoplegia due to LKA after traumatic brain injury. Interventions: He underwent conservative management for TBI followed by rehabilitation at approximately 2 months after onset. Outcomes: At 32-month after onset, weakness on left arm (Manual Muscle Test [MMT]:0) and partial weakness of left leg (MMT:3). Outcomes: Results of electromyography and nerve conduction studies of left extremities were normal. Motor evoked potential values obtained from the abductor pollicis brevis muscle (APB) were: right APB latency 22.3msec, amplitude 1.6mV; left APB latency 22.8msec, amplitude 1.5mV. After 2 weeks of administration of dopaminergic drugs for improvement of LKA, left arm weakness had recovered to level that permitted movement against gravity (MMT:3). Diffusion tensor tractography at 32-month after onset showed right corticospinal tract discontinuation at the pontine level and partial tearing of the left corticospinal tract at the subcortical white matter. In addition, the left CFT from the supplementary motor area showed partial tearing at the subcortical white matter. Lessons: The LKA due to injury of the left supplementary motor area-CFT was demonstrated in a patient with complete monoplegia following TBI. Accurate diagnosis of LKA is important for successful rehabilitation because LKA is known to respond to dopaminergic drug treatment.

Rationale: Headache is the most common physical complaint reported by the following traumatic brain injury (TBI). Several studies using diffusion tensor tractography (DTT) have demonstrated that injury of the spinothalamic tract (STT) is a pathogenetic mechanism of central pain following TBI. However, no study of headache due to injury of the STT has been reported. Patient concerns: Patient 1 was a 52-year-old female who suffered head trauma resulting from an in-car traffic crash. While sitting in a passenger seat in a moving vehicle, another vehicle suddenly hit the car from the right side. Her head hit the door and she suffered a flexion-hyperextension-rotation injury. She began to feel headaches in both fronto-parieto-occipital areas approximately 2 weeks after the crash. The characteristics and severity of pain were as follows: constant tingling and intermittent stabbing pain without allodynia or hyperalgesia (visual analogue scale score: 7). Patient 2 was a 50-year-old male who suffered head trauma from a flexion-hyperextension injury that occurred after being hit from behind by a vehicle while driving his car. He began to feel headache in both fronto-parieto-occipital areas the day after the crash: constant tingling pain without allodynia or hyperalgesia (visual analogue scale score: 6). Diagnoses: The patient 1 was diagnosed as mild TBI due to head flexion-hyperextension-rotation injury. The patient 2 was diagnosed as mild TBI due to head flexion-hyperextension injury. Interventions: Clinical assessment and DTT were performed at 5 months (patient 1) and 10 months (patient 2) after the initial injury. Outcomes: On DTTs of patient 1 and 2, the STTs showed narrowing in both hemispheres. In addition, discontinuations at the subcortical white matter were observed in both hemispheres in patient 2. Lessons: Headache due to injury of the STT was diagnosed in patients with mild TBI. Precise diagnosis of central pain from other types of pain is clinically important because the management of central pain is quite different from those for other types of pain. Our results suggest that headache might be ascribed to the injury of the STT in patients with mild TBI. Therefore, we recommend evaluation of the STT using DTT in patients with mild TBI who complain of headache having the characteristics of neuropathic pain.

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