[Embolic stroke due to ascending aortic thrombus in a patient with treatment-resistant ulcerative colitis].

The patient was a 49-year-old man presenting with recurrent melena due to progressive ulcerative colitis. One day, he developed left lower facial weakness and dysarthria, and the next day, he was transferred to our hospital because of muscle weakness in his left upper and lower extremities. On admission, neurological findings revealed left hemiplegia, including left facial palsy, dysarthria, and left hemispatial neglect. Brain MRI with diffusion-weighted image showed a fresh infarction in the right anterior and middle cerebral artery territory. Contrast-enhanced CT showed thrombus in the ascending aorta in addition to occlusion of the right internal carotid artery, suggesting the diagnosis of cerebral infarction with an embolic source in the aortic lesion. The intra-aortic thrombus disappeared after 48th day of antithrombotic therapy. Laboratory findings revealed elevated blood viscosity, proteinase-3-anti-neutrophil cytoplasmic antibody (PR3-ANCA), and ß2GP1-IgG antibodies, suggesting that the cause of the aortic thrombus may be due to elevated blood viscosity and autoantibodies, as well as highly active ulcerative colitis.

[A case of recurrent stroke with carotid-web despite dabigatran treatment successfully treated by carotid endarterectomy].

We present a case of a 41-year-old female presenting with recurrence of ischemic stroke on subtherapeutic doses of dabigatran. She had a history of embolic stroke of undetermined sources at the age of 40, and underwent implantable cardiac monitor implantation and had started dabigatran. One year after the first ischemic stroke, she presented with sudden dysarthria and left hemiparesis and was admitted to our hospital. An MRI of the head revealed acute cerebral infarction in the right corona radiata, and an MR angiography revealed right M2 occlusion. Cervical 3D-CTA revealed a protruding structure on the posterior wall of the carotid artery bulb, which was diagnosed as carotid web. She underwent carotid endarterectomy, and the specimen was pathologically confirmed to be vascular malformation due to fibromuscular dysplasia.

Pooled blood volume measured by final flat-panel detector computed tomography predicts outcome after endovascular thrombectomy for acute ischemic stroke.

Background: Pooled blood volume (PBV), measured in real-time in the angiography room using an angiography system, correlates with cerebral blood volume (CBV). We examined the usefulness of PBV in endovascular thrombectomy (EVT) for acute ischemic stroke (AIS). Methods: EVT for AIS in the anterior circulation (internal carotid artery (ICA) and middle cerebral artery (MCA)) was performed in 31 cases (13 males, 18 females, average age 75.7 years). PBV was acquired using a biplane flat-panel detector (FD) angiographic system. Then, we measured the average PBV value in the M1-6 regions similar to the Alberta Stroke Program Early CT score (ASPECTS) before and after EVT. We investigated factors associated with favorable outcome at 90 days after EVT. Results: There were 13 patients (41.9%) in the good outcome group (mRS (modified Rankin Scale) ≦2) and 18 patients (58.1%) in the poor outcome group (mRS>2). In univariate analysis, NIHSS (National Institutes of Health Stroke Scale) (odds ratio [OR] 0.74, 95% CI 0.57-0.87, p < 0.0001) and post PBV value (odds ratio [OR] 1.13, 95% CI 1.03-1.29, p = 0.0086) were significantly associated with good outcome. The good outcome group had significantly higher post-thrombectomy PBV value (3.69 ± 0.32 ml/100 g versus 2.78 ± 0.93 ml/100 g, P = 0.002) compared to that of the poor outcome group. The relationship between pre-thrombectomy PBV value and outcome at 90 days was not significant. Conclusions: Post-operative PBV value measured by FD-CT (computed tomography) correlated with 90-day outcome after EVT for AIS. FD-CT-PBV would be one of the good predictors of clinical outcome.

Early Enhancement with Contrast-Enhanced Ultrasonography Relates to the Number of Small-Diameter Neovessels in the Carotid Plaque.

BACKGROUND AND PURPOSE: Intraplaque neovessels (INVs) have been recognized as a major cause of intraplaque hemorrhage and subsequent vulnerability of the carotid plaque. However, the exact mechanisms by which INVs cause intraplaque hemorrhage remain unclear. Various sizes of INVs coexist in carotid plaques pathologically, and we hypothesized that the size of INVs would be associated with carotid plaque histology, particularly in terms of intraplaque hemorrhage. Detection method of INV is important when determining whether carotid plaques are vulnerable, and contrast-enhanced ultrasonography (CEUS) is one of the most useful methods to detect them. The purpose of this study was to examine the relationship between findings from CEUS and vascular pathology obtained by carotid endarterectomy (CEA). We focused on associations between small and large INVs evaluated by CEUS and histologically defined intraplaque hemorrhage. METHODS: Participants comprised 115 patients (mean age, 73.0 ± 7.2 years; 96 men) who underwent preoperative CEUS and underwent CEA. CEUS findings were evaluated as vascular grade at 0 min (Vas-G0) and 10 min (Vas-G10) after contrast injection. Plaques were histologically evaluated quantitatively for the total area of intraplaque hemorrhage, cholesterol, and calcification and the thinnest fibrous cap. Immunohistochemical studies were conducted using anti-CD-34 antibody as a marker for endothelial cells. INVs were divided into two groups depending on diameter: small INVs, <50 µm; and large INVs, ≥50 µm. The numbers of small and large blood vessels in the plaque were quantified histologically. Associations of small and large INVs with CEUS, plaque histology, and clinical findings were assessed by uni- and multivariable analyses. RESULTS: Multivariable analyses indicated that CEUS Vas-G0 was associated with the 4th quartile of the number of small INVs compared with other quartiles, and Vas-G10 was associated with the 4th quartile of the number of large INVs. Histologically, the presence and area of intraplaque hemorrhage were associated with the number of small INVs, while the increased number of large INVs was associated with infrequent plaque disruption and thicker fibrous cap. CONCLUSIONS: Our study showed that early phase enhancement in the CEUS can help identify plaque vulnerability by predicting a larger number of small INVs. This information can also help determine treatment strategies for carotid plaque.

Effect of Robot-assisted Rehabilitation to Botulinum Toxin A Injection for Upper Limb Disability in Patients with Chronic Stroke: A Case Series and Systematic Review.

Combining single-joint hybrid assistive limb (HAL-SJ) with botulinum toxin A (BTX-A) therapy is novel and has great therapeutic potential for the rehabilitation of stroke patients with upper limb paralysis. The purpose of this observational case series study was to evaluate the effect of BTX-A and HAL-SJ combination therapy on different exoskeleton robots used for treating upper limb paralysis. The HAL-SJ combination received a BTX-A injection followed by HAL-SJ-assisted rehabilitation for 60 min per session, 10 times per week, during 2 weeks of hospitalization. Clinical evaluations to assess motor function, limb functions used during daily activities, and spasticity were performed prior to injection, at 2-week post-treatment intervention, and at the 4-month follow-up visit. The total Fugl-Meyer assessment-upper limb (FMA-UE), proximal FMA-UE, action research arm test (ARAT), Motor Activity Log (MAL), and Disability Assessment Scale (DAS) showed a statistically significant difference, and a large effect size. However, the FMA distal assessment at 2-week post-treatment intervention showed no significant difference and a moderate effect size. The FMA-UE scores of the extracted systematic review articles showed that our design improved upper limb function. The change in the total FMA-UE score in this study showed that, compared to previous reports in the exoskeletal robotic therapy group, our combination therapy had a higher score than five of the seven references. Our results suggest that BTX-A therapy and HAL-SJ combination therapy may improve upper limb function, similar to other treatment methods in the literature.

Eosinophilic Granulomatosis with Polyangiitis Presenting with Myocarditis as an Initial Symptom: A Case Report and Review of the Literature.

A 66-year-old woman with a history of bronchial asthma had shortness of breath and fatigue upon mild exercise. She was diagnosed as congestive heart failure. A blood test showed eosinophilia without the presence of anti-neutrophil cytoplasmic antibody (ANCA), and a myocardial biopsy specimen revealed eosinophilic infiltration in the myocardium. Eosinophilia was improved when she was administered short-term methylprednisolone. After that, she had numbness and pain in her lower limbs with re-elevation of eosinophils. She had dysesthesia and hypalgesia in the distal part of the limbs. Sural nerve biopsy revealed axonal degeneration and thickness of the arterial wall, indicating a diagnosis of eosinophilic granulomatosis with polyangiitis (EGPA). Two courses of steroid pulse therapy were performed, resulting in marked improvement of her sensory symptoms. ANCA-negative EGPA might be associated with myocarditis and peripheral neuropathy. A sufficient immunotherapy should have been considered to prevent rapid progression.

Factors Predictive of Enlargement of Dissecting Aneurysms in the Vertebral Artery.

OBJECTIVE: To elucidate the incidence rate of enlargement of vertebral artery dissecting aneurysms (VADAs) during the acute phase and factors associated with enlargement. METHODS: Of 115 patients with unilateral intracranial vertebral artery dissection who did not experience subarachnoid hemorrhage, 64 with the pearl sign of vertebral artery dissection (VADA without stenosis) participated in the study. We performed initial magnetic resonance imaging to diagnose VADA and subsequent magnetic resonance imaging to evaluate VADA enlargement. The presence of a hyperintense intramural signal was confirmed using T1-weighted three-dimensional turbo spin-echo imaging. Enlargement of VADAs between the initial and subsequent examinations was evaluated via magnetic resonance angiography and defined as the end point. We studied the rate of VADA enlargement using Kaplan-Meier curve analysis. After independent variables were determined, the Cox proportional hazards model was applied in multivariable analysis to identify the factors significantly associated with VADA enlargement. RESULTS: Of 64 patients (mean age, 55.7 ± 13.0 years; 44 men and 20 women), 15 exhibited VADA enlargement. Kaplan-Meier curve analysis indicated that 24.8% of VADA enlargements were detected 30 days after initial magnetic resonance imaging. The Cox proportional hazards model revealed that young age (hazard ratio 0.953, P = 0.043) and the presence of hyperintense intramural signal (hazard ratio 2.841, P = 0.033) were significantly associated with VADA enlargement. CONCLUSIONS: VADAs enlarged by approximately 25% until day 30 after the initial examination. Younger age and the presence of hyperintense intramural signal were significantly associated with VADA enlargement.

Association of carotid ultrasonography with perioperative stroke after thoracic aortic aneurysm treatment: a retrospective study.

PURPOSE: The purpose of this study was to verify whether carotid ultrasonography (CUS) findings could be associated with the occurrence of perioperative stroke after thoracic aortic aneurysm (TAA) treatment. METHODS: Patients with TAAs who were treated by either total arch replacement or thoracic endovascular aortic repair (TEVAR) were retrospectively enrolled. Left subclavian artery (LSA) embolization and bypass surgery of the left common carotid artery (CCA) to the LSA before TEVAR were additionally performed for some patients. CUS was performed before TAA treatment to evaluate carotid atherosclerosis and flow velocities of bilateral cervical arteries. After dividing patients into those with and without perioperative stroke, their background, atherosclerotic risk factors, history of stroke, TAA location and size, treatment procedures, and CUS parameters were compared between the two groups. RESULTS: Of the 60 patients (18 women, 42 men; mean age 73.5 ± 10.2 years) with TAA, four (7.5%) developed perioperative stroke. There were no significant differences in the patients' characteristics and their TAAs between those with and without perioperative stroke. For the CUS parameters, end-diastolic velocity (EDV) of bilateral CCAs was significantly decreased in perioperative stroke patients (with vs without stroke; right: 9.2 ± 1.8 vs. 14.5 ± 4.6 cm/s, P = 0.025, left: 9.1 ± 0.3 vs. 15.0 ± 4.5 cm/s, P = 0.012), whereas the resistance index (RI) of bilateral CCAs was significantly elevated (right: 0.76 vs. 0.87, P = 0.008, left: 0.76 vs. 0.87, P < 0.001). CONCLUSIONS: Lower EDV and higher RI of bilateral CCAs were significantly associated with perioperative stroke after TAA treatment. Thus, CUS findings may help predict the occurrence of perioperative stroke.

Proposed definition for young-onset ischemic stroke according to its cause.

OBJECTIVE: Young-onset stroke has a greater social impact than does stroke in older persons, indicating the importance of its prevention. Although there have been studies comparing stroke risk factors in young versus older individuals, no definition of young-onset ischemic stroke has been established. Large extracranial and intracranial atheroma, small vessel disease and atrial fibrillation have a major role in cases of stroke in the elderly, while these disorders are much less frequent in young adults. The purpose of this study was to determine the optimal cut-off point for defining young-onset ischemic stroke according to its cause. METHODS: We identified 203 patients aged 65 years or less who had been admitted to our hospital between 2010 and 2017 with ischemic stroke, and we divided them into two groups according to the causes of the stroke. We allocated patients with strokes caused by small vessel occlusion, large artery atherosclerosis, atrial fibrillation, or aortic atheroma to Group A and those with strokes of other causes to Group B which included dissection, Trousseau syndrome and cerebral sinus thrombosis. We then used receiver operating characteristics curve analysis by the above groups and by sex to determine the cut-off age for defining young-onset. RESULTS: Group A comprised 131 patients (58 ± 7 years, 92 men, 39 women) and Group B 72 (45 ± 15 years, 47 men, 25 women). Receiver operating characteristics curve analysis to differentiate Group B from Group A in all participants indicated a cut-off value of 53 years of age (area under curve: 0.78 [0.71-0.85], P < 0.001), which we therefore considered should define young-onset ischemic stroke. After dividing all patients by their sex, ROC analyses identified a cut-off for age of between 53 and 54 years for men (AUC: 0.75, 95% CI: 0.65-0.85, P < 0.001). In comparison, ≤ 48 years was the cut-off for young ischemic stroke in women (AUC: 0.83, 95% CI: 0.71-0.94, P < 0.001). CONCLUSIONS: The age of 53 years may be the optimal cut-off point for young-onset ischemic stroke. Of note, the cut-off point between young- and non-young-onset stroke was 48 years for women, whereas it was 53 years for men. It is therefore important to carefully examine and treat female patients with this sex difference in mind.

Quantification of Carotid Plaque Histology Using iPlaque Software.

The iPlaque software package can use integrated backscatter (IB) values of carotid plaque to extract information on tissue composition. The aim of this study was to evaluate the association between the plaque histologic classification and IB values evaluated by iPlaque. In 49 patients undergoing carotid endarterectomy, IB values of whole carotid plaque were measured using iPlaque from the long-axis ultrasonographic image. Histologic findings of resected plaques were defined using the classification of the American Heart Association. The average IB values were statistically compared with the classification. Plaque samples from 49 patients were categorized into V, VI and VII, (13, 32 and 4 cases, respectively). Both the average and standard deviation of the IB values in each plaque sample significantly differed among the three classifications (p = 0.001). The IB of carotid plaque obtained by iPlaque analysis was associated with its histologic characteristics.

Detection and Differentiation of Dural Arteriovenous Fistulas in the Transverse Sinus/Sigmoid Sinus and Cavernous Sinus Using Carotid Ultrasound: Importance of Evaluation of the Occipital Artery.

OBJECTIVES: Dural arteriovenous fistula (DAVFs) in the transverse sinus (TS)/sigmoid sinus (SS) and cavernous sinus (CS) are observed frequently in the clinic. This study aimed to detect DAVFs with ultrasound and compare carotid ultrasound findings between these conditions. METHODS: We retrospectively reviewed 26 patients with either a TS/SS DAVF or a CS DAVF who were admitted to our hospital for evaluation of DAVFs from 2014 to 2018. The shunt site decision was made by neuroendovascular experts, whereas carotid ultrasound examinations were performed by ultrasound specialists. The flow velocity of the ipsilateral external carotid artery was reviewed in all 26 patients, whereas that of the occipital artery (OA) was examined in 20 patients. Blood flow velocities were compared between the TS/SS DAVF and CS DAVF groups. RESULTS: The study included 18 patients with a TS/SS DAVF (11 women and 7 men; mean age ± SD, 65.3 ± 18.6 years) and 8 patients with a CS DAVF (7 women and 1 man; mean age, 70.4 ± 9.3 years). Evaluations of feeder arteries on cerebral angiography showed that all patients had dural branches from the internal carotid and middle meningeal arteries as feeders of CS DAVFs, whereas the OA was the major feeder source of all TS/SS DAVF cases. The end-diastolic velocity (EDV) of the external carotid artery was significantly higher in patients with a TS/SS DAVF compared with those with a CS DAVF (P = .004). The EDV of the OA was significantly elevated in TS/SS DAVF cases compared with CS DAVF cases (P < .001). CONCLUSIONS: Duplex ultrasound parameters are significantly different between patients with TS/SS and CS DAVFs. An increased EDV of the OA can predict the presence of a TS/SS DAVF.

Qualitative and Comparative Cortical Activity Data Analyses from a Functional Near-Infrared Spectroscopy Experiment Applying Block Design.

Neuroimaging studies play a pivotal role in the evaluation of pre- vs. post-interventional neurological conditions such as in rehabilitation and surgical treatment. Among the many neuroimaging technologies used to measure brain activity, functional near-infrared spectroscopy (fNIRS) enables the evaluation of dynamic cortical activities by measuring the local hemoglobin levels similar to functional magnetic resonance imaging (fMRI). Also, due to lesser physical restriction in fNIRS, multiple variants of sensorimotor tasks can be evaluated. Many laboratories have developed several methods for fNIRS data analysis; however, despite the fact that the general principles are the same, there is no universally standardized method. Here, we present the qualitative and comparative analytic methods of data obtained from a multi-channel fNIRS experiment using a block design. For qualitative analysis, we used a software for NIRS as a mass-univariate approach based on the generalized linear model. The NIRS-SPM analysis shows qualitative results for each session by visualizing the activated area during the task. In addition, the non-invasive three-dimensional digitizer can be used to estimate the fNIRS channel locations relative to the brain. To corroborate the NIRS-SPM findings, the amplitude of the changes in hemoglobin levels induced by the sensorimotor task can be statistically analyzed by comparing the data obtained from two different sessions (before and after intervention) of the same study subject using a multi-channel hierarchical mixed model. Our methods can be used to measure the pre- vs. post-intervention analysis in a variety of neurological disorders such as movement disorders, cerebrovascular diseases, and neuropsychiatric disorders.

Feasibility of single and combined with other treatments using transcranial direct current stimulation for chronic stroke: A pilot study.

OBJECTIVES: This pilot study aimed to investigate the safety and efficacy of transcranial direct current stimulation (tDCS) for chronic stroke in adult and pediatric patients. We also aimed to verify the efficacy of botulinum toxin A and peripheral neuromuscular electrical stimulation combined therapy involving bilateral tDCS in adult patients with chronic stroke. METHODS: We conducted a pilot study applying an unblinded, non-randomized design. Eleven patients were recruited, and classified into three groups. Group I-a involved bilateral transcranial direct current stimulation and intensive occupational therapy for chronic stroke in adult patients. Group I-b involved bilateral tDCS and intensive occupational therapy for chronic stroke in pediatric patients. Group II involved bilateral tDCS, peripheral neuromuscular electrical stimulation, and intensive occupational therapy after botulinum toxin A injection for chronic stroke in adult patients. Clinical evaluations to assess motor function and spasticity were performed at baseline as well as in 2-week and 4-month follow-up visits. The questionnaire included questions regarding the presence of tDCS side effects, such as headache, redness, pain, itching, and fever. RESULTS: There were clinically meaningful changes in total Fugl-Meyer Assessment Upper Extremity (FMA-UE) scores at the 2-week follow-up and in the Action Research Arm Test (ARAT) scores at 4-month follow-up in Group I-b. In addition, Group II showed significant improvement in total FMA-UE scores in the 2-week follow-up (p < 0.05) but not on the ARAT scores (p > 0.05). However, Group II showed improvements in total Motor Activity Log scores at both follow-up visits (p < 0.05). No serious adverse events were reported. CONCLUSION: The results of this study indicate that tDCS therapy is a potential treatment in pediatric patients with chronic stroke. Furthermore, our data indicate that botulinum toxin A and peripheral neuromuscular electrical stimulation combined therapy may enhance the efficacy of tDCS on motor function.

Isolated Cerebral Vasculitis in the Unilateral Middle Cerebral Artery in a Case with SLE.

A 47-year-old woman, who was diagnosed to have systemic lupus erythematosus (SLE), was admitted because she suffered a severe ischemic stroke three weeks after experiencing a transient attack of aphasia. Diffusion-weighted MRI revealed high intensity at the borderzone of the middle cerebral artery (MCA), while the proximal portion of the left MCA was occluded with its vascular wall enhanced by gadolinium. Intravenous methylprednisolone and heparin were administrated without any symptomatic benefit. She developed severe right hemiparesis with aphasia. Isolated cerebral vasculitis in the large vessel has been rarely reported in SLE patients. The presence of an enhanced vascular wall in the MRI with gadolinium could support the diagnosis.

Feasibility of Robot-assisted Rehabilitation in Poststroke Recovery of Upper Limb Function Depending on the Severity.

The single-joint Hybrid Assistive Limb (HAL-SJ) robot is an exoskeleton-type suit developed for the neurorehabilitation of upper limb function. Several studies have addressed the usefulness of the robot; however, the appropriate patient selection remains unclear. In this study, we evaluated the effectiveness of the HAL-SJ exoskeleton in improving upper limb function in the subacute phase after a stroke, as a function of the severity of arm paralysis. Our analysis was based on a retrospective review of 35 patients, treated using the HAL-SJ exoskeleton in the subacute phase after their stroke, between October 2014 and December 2018. The severity of upper limb impairment was quantified using the Brunnstrom recovery stage (BRS) as follows: severe, BRS score 1-2, n = 10; moderate, BRS 3-4, n = 12; and mild, BRS 5-6, n = 13. The primary endpoint was the improvement in upper limb function, from baseline to post-intervention, measured using the Fugl-Meyer assessment upper limb motor score (ΔFMA-UE; range 0-66). The ΔFMA-UE score was significant for all three severity groups (P <0.05). The magnitude of improvement was greater in the moderate group than in the mild group (P <0.05). The greatest improvement was attained for patients with a moderate level of upper limb impairment at baseline. Our findings support the feasibility of the HAL-SJ to improve upper limb function in the subacute phase after a stroke with appropriate patient selection. This study is the first report showing the effect of robot-assisted rehabilitation using the HAL-SJ, according to the severity of paralysis in acute stroke patients with upper extremity motor deficits.

Serum B-type natriuretic peptide level and timing of its measurement as a predictor of acute ischemic stroke outcome.

An increased B-type natriuretic peptide (BNP) level is associated with cardioembolic stroke because of atrial fibrillation. However, data associating the measurement time of BNP and clinical influence of BNP are limited. Herein, we examined the utility of BNP level for prediction of stroke severity when accounting for measurement time. We retrospectively registered 327 patients admitted within 7 days from onset of ischemic stroke. We collected information on patients' background, stroke risk factors, subtype and severity, and outcome at discharge. Measurement of BNP was performed by chemiluminescent enzyme immunoassay. Patients were divided into 3 groups according to the time of BNP measurement from disease onset. Multivariate analyses were performed to evaluate the association of BNP value with outcome after patients were grouped according to BNP measurement time. Of the 327 patients, the numbers of patients whose BNP was measured within 24 h of symptom onset, between 24 and 48 h of symptom onset, and after 48 h of symptom onset were 102, 92, and 133, respectively. Favourable outcome at discharge was negatively correlated with BNP value in patients with a BNP level measured within 24 h of stroke onset. BNP value may be useful for prediction of stroke outcome if measured within 24 h after stroke onset.

Increased Plasma VEGF Levels in Patients with Cerebral Large Artery Disease Are Associated with Cerebral Microbleeds.

BACKGROUND/PURPOSE: Because atherosclerotic factors and antithrombotic agents sometimes induce cerebral microbleeds (CMBs), patients with cerebral large artery disease (CLAD) tend to have more CMBs than control subjects. On the other hand, VEGF contributes to the disruption of the blood-brain barrier, and it may induce parenchymal edema and bleeding. We conducted a study to evaluate the role of vascular endothelial growth factor (VEGF) in the occurrence of CMBs in patients with CLAD. METHODS: CLAD is defined as stenosis or occlusion of either the carotid artery or the middle cerebral artery of 50% or more. We prospectively registered patients with CLAD who were hospitalized in our neurocenter. Biological backgrounds, atherosclerotic risk factors, administration of antithrombotics before hospitalization, and levels of cytokines and chemokines were evaluated. Susceptibility-weighted imaging or T2*-weighted MR angiography was used to evaluate CMBs. The Brain Observer MicroBleed Scale (BOMBS) was used for CMB assessments. Images were analyzed with regard to the presence or absence of CMBs. We also examined plasma VEGF concentrations using a commercial ELISA kit. Because more than half showed plasma VEGF levels below assay detection limits (3.2 pg/mL), the patients were dichotomized by plasma VEGF levels into two groups (above and below the detection limit). After univariate analyses, logistic regression analysis was conducted to determine the factors associated with the CMBs after adjustment for age, sex, the presence of hypertension, and administration of antithrombotic agents. A similar analysis with CMBs separated by location (cortex, subcortex, or posterior circulation) was also conducted. RESULTS: Sixty-six patients (71.1 ± 8.9 years, 53 males and 13 females) were included in this study. Plasma VEGF levels were not correlated with age, sex, and atherosclerotic risk factors; however, patients with VEGF levels >3.2 pg/mL tended toward more frequent CMBs (60.0 vs. 32.6%, in the presence and absence of CMBs, p = 0.056). With regard to the location of CMBs, those in the cortex and/or at the gray-white junction were observed more frequently in the patients with VEGF levels >3.2 pg/mL after multivariable analyses (odds ratio: 3.80; 95% confidence interval: 1.07-13.5; p = 0.039). CONCLUSIONS: In patients with CLAD, elevated plasma VEGF might be associated with CMBs, especially those located in the cortex and/or at the gray-white junction.

Impact of cerebral large-artery disease and blood flow in the posterior cerebral artery territory on cognitive function.

OBJECTIVES: The purpose of this study was to elucidate the association of cerebral large artery disease (CLAD) with cerebral blood flow (CBF) in the posterior cerebral artery (PCA) territory and cognitive performance. METHOD: We prospectively registered patients with CLAD who had internal carotid or middle cerebral artery (MCA) with the degree of stenosis ≥50%. Automated brain segmentation was used to quantify CBF in the thalamus, hippocampus, and PCA and MCA territories. We measured cognitive function of patients using the Wechsler Memory Scale Revised (WMS-R), the Mini-Mental State Examination (MMSE), and the Montreal Cognitive Assessment. Patients were divided into 3 groups according to CBF of the cortical and subcortical PCA territory. RESULTS: There were 60 patients included in this study. The degree of stenosis was significantly correlated with CBF in the PCA territory (Γ = 0.35, P = .006) and hippocampus (Γ = 0.34, P = .008). Verbal memory, general memory, and reproduction on WMS-R and MMSE were significantly reduced areas with low CBF in the PCA territory compared with areas with middle and high CBF. CONCLUSIONS: CBF of the PCA territory was significantly inversely correlated with the degree of stenosis in CLAD patients. Low CBF of the PCA territory was significantly associated with reduced cognitive and memory functions.

The Comparison of Clinical Findings and Treatment Between Unilateral and Bilateral Vertebral Artery Dissection.

BACKGROUND: There are limited clinical studies of bilateral vertebral artery dissection (VAD). OBJECTIVE: To compare the characteristics, imaging findings, and treatments between patients with bilateral and unilateral VAD. METHODS: Between February 2007 and May 2017, 31 (mean age: 53.0 years; 23 men, 8 women) out of 171 VAD patients were hospitalized because of bilateral VAD. Onset type, dissection site, dominant side of the VA, imaging features, treatments, and outcomes were investigated based on medical records. The dominant side of the VA was determined by basi-parallel anatomical scanning. RESULTS: Twenty (64.5%) of 31 patients exhibited bilateral VAD on both sides of V4. The dominant side of the VA was right in 16 patients and left in 15 patients. The pearl and string sign (an angiographical finding with both dilatation and stenosis) was frequently observed on the dominant VAD side, while a tapered occlusion and string sign were most common on the nondominant side. For clinical subtype of VAD, 6 (19.4%) patients had subarachnoid hemorrhage, 10 (32.3%) ischemic stroke, 3 (9.7%) infarction plus subarachnoid hemorrhage, and 12 (38.7%) only headache. The frequency of infarction was increased in bilateral VAD compared with unilateral (P < .05). Surgical intervention was performed in 3 cases, while 14 patients received endovascular intervention. CONCLUSIONS: Infarction occurred frequently in bilateral VAD patients, and 17 patients required an intervention (mainly endovascular) for VA. The treatment strategy varied depending on the clinical subtype, imaging findings of VAD, and morphology of the dominant VAD side.

Pituitary metastasis of breast cancer mimicking IgG4-related hypophysitis.

IgG4-related hypophysitis, which is the pituitary gland inflammation caused by IgG4 positive lymphocytes, can affect cavernous sinus and orbital apex leading to developing cranial nerve related symptoms such as orbital apex syndrome (OAS). Here we report a case of hypopituitarism associated with OAS caused by pituitary metastasis of the breast cancer with elevated serum IgG4 level, who initially resembled to IgG4-related hypophysitis. Although this case had some features in common with igG4-related hypophysitis. The symptoms and pituitary enlargement were typical. However, steroid treatment did not improve her symptoms. Thus, we performed a tissue biopsy. Histopathologic examination of the hypophyseal tumor confirmed metastatic breast cancer in her pituitary. Pituitary metastatic tumor should be suspected if a case with OAS was once diagnosed as a cancer.