All of the patients with normal urodynamic studies were aphasic, demented, or severely functionally impaired. Urodynamic studies, performed on all 19 incontinent patients, revealed bladder hyperreflexia in 37%, normal studies in 37%, bladder hyporeflexia in 21%, and detrusor-sphincter dyssynergia in 5%. Incontinence was associated with large infarcts, aphasia, cognitive impairment, and functional disability (p < 0.05) but not with age, sex, side of stroke, or time from stroke to entry in the study. Nineteen patients (37%) were incontinent. ![]() Urodynamic studies were performed on all incontinent patients. The presence of urinary incontinence was correlated with infarct location, neurological deficits, and functional status. 9 Patients having anterior cortical lesion with bladder disruption have various etiologies as in anterior cerebral artery aneurysms, tumors, or stroke in the mesial frontal lobes.We prospectively studied bladder function in stroke patients to determine the mechanisms responsible for poststroke urinary incontinence.įifty-one patients with recent unilateral ischemic hemispheric stroke admitted to a neurorehabilitation unit were enrolled. There is more of a correlation of urinary disturbance and hemiparesis with a more anterior brain lesion, as seen in our case. 7, 8 There are reports of transient incontinence associated with damage to the superior prefrontal region. 6 Others have found multiple other areas of activation during voiding. 6 In addition, there is increased activity with decreased urge to void at the cingulate cortex and premotor cortex. 5 Cortical activation within the mid-cingulate cortex and the bilateral frontal lobe has also been noted. 4 This has also been supported by others. 4 The intended action to urinate was localized to the right inferior frontal gyrus and right anterior cingulate gyrus. Positron emission tomography (PET) scans showed significant activity in the right inferior frontal gyrus and the right anterior cingulate gyrus during voiding. ![]() In a review of the literature, multiple areas of the brain are involved in micturition. Pathway of the bladder from the cortex at the sphincter control and micturition inhibition center to the pontine micturition center, down the spinal cord to the sympathetics and parasympathetics to its final destination. Most notably, there was an infarction of the left internal frontal hemispheric convexity, corresponding to the frontal micturition area of the somatosensory homunculus ( Figure 1B). There were no contraindications to intravenous recombinant tissue-plasminogen activator (rt-pa), and the patient received 0.9 mg/kg alteplase 1 hour and 46 minutes after symptom onset.įollow-up brain magnetic resonance imaging (MRI) demonstrated multiple tiny infarctions in both hemispheres, suggestive of a proximal source of embolism ( Figure 1A). Multimodal CT with angiography demonstrated a filling defect at the A1 segment of the left anterior cerebral artery, suggestive of intraluminal thrombus. The noncontrast head computed tomography (CT) demonstrated no hemorrhage or other acute intracranial abnormality. The National Institutes of Health Stroke scale score was 1. The sensory, coordination, and language examinations were normal. There was no facial asymmetry, arm weakness, dysarthria, or visual field deficit. The neurologic examination was remarkable for drift in the right lower extremity. The general physical examination was remarkable for a blood pressure of 161/110 and an irregularly irregular cardiac rhythm suggestive of atrial fibrillation. ![]() He was not treated with oral anticoagulants. He denied loss of consciousness, involuntary movements, or headache. ![]() He also reportedly had mild right arm weakness and numbness that resolved prior to arrival to the emergency room. A 65-year-old man with a history of atrial fibrillation, hypertension, hyperlipidemia, and glucose intolerance presented to the emergency department after developing the sudden onset of right leg weakness and numbness with urinary incontinence.
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