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Predictive value of the ischemic stroke lesion to detrusor function

Dear Editor: Urgency and urinary incontinence in stroke patients are common, and the prevalence is closely associated with the size of the cerebral infarction. Such urinary symptoms cause considerable stress to stroke patients and decrease quality of life. Prevalence of urinary incontinence range from 32% to 79% in the acute stage of stroke, decreasing to 25–28% at the time of hospital discharge. At several months after stroke, prevalence is present in 12–19%. The location of ischemic stroke lesion is suggestive to affect the type of detrusor dysfunction, but no such data has been published about this subject. Generally, normal bladder and urethral afferents received in the periaqueductal gray are located in the insula, forming the basis of sensation in storage phase. The anterior cingulated gyrus provides monitoring and control, and the prefrontal cortex makes voiding decisions. The pontine micturition center inhibits bladder contraction. In damaged brain, detrusor overactivity (DO) seems to be prefrontal deactivation, but detrusor dysfunction is affected by various parts of brain. We have collected 62 cases among 142 ischemic stroke patients who underwent the urodynamic study because of lower urinary tract symptoms from June 2003 to September 2009. Exclusion criteria were hemorrhagic stroke, diabetes mellitus cystopathy, benign prostate hyperplasia, previous pelvic surgery, and other neurologic etiology. Urodynamic tests were performed using the Libra (MMS, Enschede, the Netherlands) urodynamic test system as usual manner. DO was defined as a bladder capacity of lower than 300ml, and detrusor underactivity (DU) was defined that patient could not void or had postvoid residual urine of more than 50ml. According to urodynamic studies, we divided 62 cases into two groups; DO and DU, and analyzed the localization of brain lesion in Table I. There were no significant statistical differences in the location of brain lesion such as frontal lobe, parietal lobe, temporal lobe, occipital lobe, basal ganglia, thalamus, paraventricle, subcortical white matter, brain stem between DO and DU groups. Our previous study suggested that evaluation of the stroke type may be helpful in the determination of the type of urinary dysfunction and in deciding the appropriate bladder management. But we found no significance between the localization of lesion and the type of urinary dysfunction. Two major modulatory cholinergic systems in the human brain are the basal forebrain complex and diffuse cholinergic system in the pons and midbrain. In animal studies, the reactivation of these regulatory systems using acetylcholinesterase inhibitor could improve DO. But the regulatory systems of the damaged human brain maybe more complexed. There were several studies about excitatory amino acids andmonoaminergic neurotransmitter release during ischemia in different animal stroke models of focal and global ischemia. Kanthan et al. concluded that neurotransmitter and metabolites can be detected in the human stroke model and significant changes to partial and total ischemia were noted in the extracellular levels of 5-hydroxyindoleacetic acid and serotonin. But the exact role played by the differential