Incidence of oral anticoagulant interruption among stroke patients with atrial fibrillation and subsequent stroke.

BACKGROUND AND PURPOSE: We analyzed the incidence and causes of oral anticoagulant (OAC) cessation and subsequent stroke after OAC withdrawal in a cohort of Korean stroke patients with atrial fibrillation. METHODS: The Korean Atrial Fibrillation Evaluation Registry in Ischemic Stroke patients (K-ATTENTION) is a multicenter cohort study, merging stroke registries from 11 tertiary centers in Korea. The number of OAC interruption episodes and the reasons were reviewed from hospital records. Stroke after OAC withdrawal was defined when a patient experienced ischaemic stroke within 31 days after OAC withdrawal. Clinical variables were compared between patients who experienced stroke recurrence during OAC interruption and those who did not experience recurrence. RESULTS: Among 3213 stroke patients with atrial fibrillation, a total of 329 episodes of OAC interruption were detected in 229 patients after index stroke (mean age 72.9 ± 8.3 years, 113 female patients). The most frequent reason for OAC withdrawal was poor compliance [103 episodes (31.3%)] followed by extracranial bleeding [96 episodes (29.2%)]. Stroke after OAC withdrawal was noted in 13 patients. Mean age, vascular risk factor profile and mean CHA2 DS2 -VASc score were not significantly different between patients with and without recurrent stroke. CONCLUSIONS: A considerable number of stroke patients with atrial fibrillation experienced temporary interruption of OAC after index stroke, which was associated with stroke recurrence of 4.0 cases per 100 interruption episodes.

A systemic lupus erythematosus patient with thunderclap headache: reversible cerebral vasoconstriction syndrome.

Headaches are common in patients with systemic lupus erythematosus (SLE). It is important to identify the exact cause of headaches in SLE to avoid unnecessary steroid or immunosuppressive therapy like in neuropsychiatric SLE. A 35-year-old woman with SLE suddenly developed severe headache. Magnetic resonance angiography showed multifocal segmental narrowing of cerebral arteries, suggestive of central nervous system vasculitis. However, lack of abnormal enhancement in vessel wall imaging indicated reversible cerebral vasoconstriction syndrome (RCVS) rather than central nervous system vasculitis. The patient was treated with oral nimodipine and she recovered over a period of two months. Following magnetic resonance angiography on day 90 was normal. Herein we report a case of reversible cerebral vasoconstriction syndrome in an SLE patient with literature review.

White matter hyperintensities and recurrent stroke risk in patients with stroke with small-vessel disease.

BACKGROUND AND PURPOSE: White matter hyperintensities (WMH) are a predictor of stroke among elderly individuals. This study aimed to evaluate the association between WMH severity and the risk of recurrent vascular events among Asian patients with ischaemic stroke with small-vessel disease (SVD) including micro/macrobleeds and lacunes. METHODS: Data from participants (n = 1454) in the PICASSO (PreventIon of CArdiovascular Events in iSchemic Stroke Patients with High Risk of Cerebral HemOrrhage) trial were reviewed. The severity of WMH in baseline brain magnetic resonance imaging scans was assessed using the Fazekas scale. The association between WMH severity and stroke (ischaemic or hemorrhagic) and major vascular events (MVEs) (a composite of stroke/myocardial infarction/vascular death) was assessed. RESULTS: Study patients had a significant burden of SVD: Fazekas score 0 (n = 2), 1 (n = 426), 2 (n = 650) and 3 (n = 376) [median Fazekas score 2 (mean follow-up, 1.9 ± 1.3 years)]. The stroke incidence rate per 100 personyears was 2.6 in the Fazekas 0-1 group, 3.6 in the Fazekas 2 group and 7.0 in the Fazekas 3 group, and the rates for MVEs were 3.3, 4.3 and 7.6, respectively. Compared with the Fazekas 0-1 group, the Fazekas 3 group was associated with a higher risk of stroke [adjusted hazard ratio (HR), 2.15; 95% confidence interval (CI), 1.19-3.88; P = 0.011], ischaemic stroke (adjusted HR, 2.11; 95% CI, 1.07-4.15; P = 0.031), hemorrhagic stroke (adjusted HR, 3.72; 95% CI, 1.09-12.70; P = 0.036) and MVEs (adjusted HR, 2.09; 95% CI, 1.20-3.66; P = 0.010). CONCLUSION: Advanced WMH in Asian patients with ischaemic stroke with SVD burden was associated with an increased risk of recurrent vascular events. It may exert an effect as a prognostic indicator in high risk of recurrent vascular events.

Recent Results of In Situ Abdominal Aortic Reconstruction with Cryopreserved Arterial Allograft.

OBJECTIVE: To evaluate treatment outcomes of in situ abdominal aortic reconstruction with cryopreserved arterial allograft (CAA) for patients with abdominal aortic infection. MATERIALS AND METHODS: A retrospective review of prospectively collected data was conducted of patients who underwent in situ aortic reconstruction using CAA for primary, secondary, or prosthetic infection of the abdominal aorta between May 2006 and July 2015, at a single institution. Clinical presentation, indications for treatment, procedural details, early post-operative mortality and morbidity, late death, and graft related complications during the follow up period were investigated. Patient survival and event free survival (any death or re-operation) were calculated using the Kaplan-Meier method. RESULTS: Twenty-five patients (male, n = 20, 80%; mean age, 70.2 ± 8.7 years) underwent in situ abdominal aortic reconstruction (48% aortic, 52% aorto-bi-iliac) with vessel size and ABO matched CAA for treatment of abdominal aortic infection caused by infected abdominal aortic aneurysm (n = 15), aortic prosthesis infection (n = 7), aortic reconstruction with concomitant colon resection (n = 2), and primary suppurative aortitis (n = 1). The median follow up was 19.1 months (range 1-73 months). There were seven post-operative deaths including two (8%) early (<30 days) and five (20%) late deaths There were three (12%) graft related complications including thrombotic occlusion of the CAA, aneurysmal dilatation, and aorto-enteric fistula. Three years after CAA implantation, patient survival was 74% and the event free survival was 58%. CONCLUSIONS: It is believed that in situ abdominal aortic reconstruction with CAA is a useful option for treating primary, secondary, or prosthetic infection of the abdominal aorta.

PIN1 inhibition suppresses osteoclast differentiation and inflammatory responses.

Inflammatory responses and osteoclast differentiation play pivotal roles in the pathogenesis of osteolytic bone diseases such as periodontitis. Although overexpression or inhibition of peptidyl-prolyl cis/trans isomerase NIMA-interacting 1 (PIN1) offers a possible therapeutic strategy for chronic inflammatory diseases, the role of PIN1 in periodontal disease is unclear. The aim of the present study was to evaluate PIN1 expression in periodontitis patients as well as the effects of PIN1 inhibition by juglone or PIN1 small-interfering RNA (siRNA) and of PIN1 overexpression using a recombinant adenovirus encoding PIN1 (Ad-PIN1) on the inflammatory response and osteoclastic differentiation in lipopolysaccharide (LPS)- and nicotine-stimulated human periodontal ligament cells (PDLCs). PIN1 was up-regulated in chronically inflamed PDLCs from periodontitis patients and in LPS- and nicotine-exposed PDLCs. Inhibition of PIN1 by juglone or knockdown of PIN1 gene expression by siRNA markedly attenuated LPS- and nicotine-stimulated prostaglandin E2 (PGE2) and nitric oxide (NO) production, as well as cyclooxygenase-2 (COX-2) and inducible nitric oxide synthase (iNOS) expression, whereas PIN1 overexpression by Ad-PIN1 increased it. LPS- and nicotine-induced nuclear factor (NF)-κB activation was blocked by juglone and PIN1 siRNA but increased by Ad-PIN1. Conditioned medium prepared from LPS- and nicotine-treated PDLCs increased the number of tartrate-resistant acid phosphatase-stained osteoclasts and osteoclast-specific gene expression. These responses were blocked by PIN1 inhibition and silencing but stimulated by Ad-PIN1. Furthermore, juglone and PIN1 siRNA inhibited LPS- and nicotine-induced osteoclastogenic cytokine expression in PDLCs. This study is the first to demonstrate that PIN1 inhibition exhibits anti-inflammatory effects and blocks osteoclastic differentiation in LPS- and nicotine-treated PDLCs. PIN1 inhibition may be a therapeutic strategy for inflammatory osteolysis in periodontal disease.

Unusual manifestation of endometrioid adenocarcinoma arising from subserosal cystic adenomyosis of the uterus: emphasis on MRI and positron emission tomography CT findings.

There are several reports of adenocarcinoma developing within adenomyosis of the uterus, but imaging features of MRI, including diffusion-weighted imaging (DWI) and positron emission tomography (PET)-CT, have not been published. Herein we report a rare case of endometrioid adenocarcinoma arising from subserosal cystic adenomyosis to emphasise the unusual growth features, as well as the imaging findings of the tumour on MRI and PET-CT.

Alveolar soft part sarcoma of the uterine cervix in a woman presenting with postmenopausal bleeding: a case report and literature review.

INTRODUCTION: Alveolar soft part sarcoma (ASPS) of the uterine cervix is a rare mesenchymal malignancy that occurs in adolescents and young adults. CASE REPORT: A 52-year-old postmenopausal woman presented with profuse vaginal bleeding of one month's duration with severe anemia. The pelvic examination revealed a 3 cm mass on the posterior lip of the uterine cervix. On magnetic resonance imaging, the tumor had high signal intensity on T1- and T2-weighted images. A modified radical hysterectomy and bilateral salpingo-oophorectomy were performed. Immunohistochemical staining for TFE3 and electron microscopic examination revealed an ASPS of the uterine cervix. DISCUSSION: The better prognosis of cervical ASPS, compared to the soft counterparts, may be related to early clinical detection, small size, resectability, and demarcation of the tumor.

An uncommon anastomosis of the posterior inferior cerebellar artery and the external carotid artery with the patent vertebrobasilar system.

The hypoglossal artery arises as a branch of the internal carotid artery and traverses the hypoglossal canal. However, the hypoglossal artery arising from the external carotid artery (ECA) and connecting directly with the posterior inferior cerebellar artery (PICA), instead of the basilar artery or the vertebral artery, is very rare. We present a case of an uncommon variant of the hypoglossal artery arising from the ECA that connected directly with the PICA.

A case of unilateral hemispheric encephalitis.

Herein we report a case of encephalitis involving the unilateral hemisphere, with a clinical course different from that of Rasmussen syndrome. A 44-year-old man visited us because of headache and language abnormality. Cerebrospinal fluid examination showed lymphocytosis with increased level of protein. Brain MRI showed abnormal findings limited to the unilateral hemisphere. The symptoms and signs improved without any specific antiviral treatment in a week. However, language disturbance and right hemiparesis developed after a week. Steroid therapy was effective. He recovered without any neurologic sequelae. Our case was unusual encephalitis involving the unilateral hemisphere, which was benign and steroid-responsive.