Feasibility of Mechanical Thrombectomy for Acute Ischemic Stroke Patients Aged 90 Years or Older Compared to Younger Patients.

Mechanical thrombectomy (MT) is a proven treatment for acute ischemic stroke (AIS). However, the efficacy of this treatment is uncertain for very elderly patients. This study aimed to investigate the safety and effectiveness of MT in 90 years or older patients compared with younger patients. We retrospectively reviewed AIS patients treated with MT between October 2018 and June 2020 in our institution. Patients were divided into two groups: aged ≥90 and <90 years. We compared the following factors: functional outcome at discharge, in-hospital death, successful recanalization, and complications. Multivariate logistic regression analysis for the good functional outcome was performed. In consideration of pre-stroke basic activities of very elderly patients, we defined the good functional outcome as modified Rankin Scale (mRS) 0-3. In all, 66 patients were included, and 19 patients (28%) were ≥90 years old. Pre-stoke mRS was higher in ≥90-year-old patients (p = 0.01). In ≥90-year-old patients, we achieved successful recanalization in 17 patients (90%), and only one patient experienced hemorrhagic complication related with the procedure. The good functional outcome (mRS: 0-3) at discharge were six patients (32%) in ≥90 years old versus 19 patients (40%) in <90 years old (p = 0.6). Three patients died in hospital in each group (16% versus 6%) (p = 0.3). Only the stroke severity was negatively related with the good functional outcome in a multivariate analysis. In conclusion, for ≥90-year-old patients compared with younger patients, MT is an equally feasible therapy. Patients should not be excluded from MT based on age alone.

A Potential New Risk Factor for Stroke: Streptococcus Mutans With Collagen-Binding Protein.

BACKGROUND: Among human oral bacteria, particular kinds of Streptococcus mutans (SM) known as dental caries pathogens contain a collagen-binding protein, Cnm, and show platelet aggregation inhibition and matrix metalloproteinase-9 activation. We have previously reported that these strains may be a risk factor for intracerebral hemorrhage. As a major sample-providing hospital, we report the clinical details, including intracranial aneurysms and ischemic stroke. METHODS: After the study received approval from the Ethical Committee, 429 samples of whole saliva were obtained from patients who were admitted to or visited our hospital between February 16, 2010, and February 28, 2011. The study cohort comprised 48 patients with cardioembolic stroke (CES), 151 with non-CES infarct, 54 with intracerebral hemorrhage (ICH), 43 with ruptured intracranial aneurysm (RIA), and 97 with unruptured intracranial aneurysm (UIA). Cultured SM was identified as Cnm-positive when the corresponding gene was positive. The results were compared with those from 79 healthy volunteers. Relationships between Cnm-positive SM and known risk factors, including hypertension, diabetes, hyperlipidemia, smoking, and alcohol consumption, were analyzed. RESULTS: A statistically significant high Cnm-positive rate was observed in patients with CES, non-CES infarct, ICH, and RIA (P = 0.002, 0.039, 0.013, and 0.009, respectively). There were no relationships between Cnm-positive SM and known risk factors. CONCLUSIONS: Specific types of oral SM can be a risk factor for cardioembolic infarct, intracerebral hemorrhage, and intracranial aneurysm rupture. Further study is needed.

[Ischemic changes and blood coagulation abnormalities as complications of pneumococcal meningitis].

One explanation for cerebral infarctions that occur as a complication of pneumococcal meningitis is blood coagulation abnormalities. We investigated the clinical features, laboratory test results, magnetic resonance imaging (MRI) findings, and pathological features of 10 patients with pneumococcal meningitis between 2006 and 2013 to examine the abnormal findings that may be associated with prognosis. Five patients (50%) that had Glasgow Outcome Scale scores between 1 and 4 were classified as the poor outcome group. In this group, the MRI revealed a high signal intensity on the diffusion-weighted image (DWI), and there was an abnormal signal along the cerebral cortex and Virchow-Robin spaces, which were characterized pathologically by ischemic changes. The plasma thrombin-antithrombin complex (TAT) levels showed greater differences between the poor and good prognosis groups than platlet and D-dimer levels; this suggested that high plasma TAT levels indicate a poor prognosis.

[Acute encephalitis with refractory partial status epilepticus treated with early immunotherapies including plasma exchange: a case report].

We describe a patient of acute encephalitis with refractory partial status epilepticus who was successfully treated with early immunotherapy. A 35-year-old male presented with generalized seizures a week after febrile upper respiratory illness. He developed refractory multifocal and generalized seizures despite multiple antiepileptic drug therapies, thereby requiring intubation on the 8(th) day after admission. No significant improvement was observed after steroid pulse and intravenous immunoglobulin (IVIG) therapies. On the 18(th) day, he received plasma exchange (PE) therapy in combination with intravenous thiamylal and lidocaine to achieve burst-suppression coma. This multidisciplinary treatment led to remission of refractory status epilepticus and subsequent withdrawal from general anesthesia. Although anti-N-methyl-D-aspartate receptor antibodies in cerebrospinal fluid were negative, other neural surface antibodies may responsible for the development of status epilepticus in this case. Clinical features in this case, including previous good health, an antecedent febrile illness, and prolonged treatment-resistant status epilepticus, were similar to those of the acute phase of new-onset refractory status epilepticus (NORSE) syndrome. Consecutive use of glucocorticoids, IVIG, and PE in the early phase was speculated to ameliorate seizures by suppressing abnormal activation of humoral immunity. This indicates that early aggressive immunotherapy may prevent complications resulting from immune-mediated treatment-resistant status epilepticus.

[Effectiveness and role of lamotrigine in the paradigm shift towards new antiepileptic drugs: a therapeutic strategy proposed after an investigation of a large number of cases at a single hospital].

Lamotrigine (LTG) has been recognized as one of the best newer antiepileptic drugs (AEDs) used in developed countries since 1991. A retrospective study was carried out to evaluate the efficacy, adverse reactions, and other peculiarities of LTG. Two hundred and eighty-one patients with epilepsy, aged 16 or more, were treated with LTG between December 2008 and December 2012 at the Seirei Hamamatsu General Hospital. One hundred and forty patients were found to be eligible to evaluate the effectiveness of LTG. Of them, 100 patients had localized epilepsy, and 40 patients had generalized epilepsy. Seventy-five out of these 140 (53.6%) patients obtained seizure freedom following LTG use, and 24 patients (17.1%) showed more than 50% seizure reduction, which indicates that a total of 99 patients (70.7%) were good responders. A seizure reduction of less than 50% was seen in 8 patients (5.7%), whereas 30 patients (21.4%) did not display any obvious seizure reduction. Three patients (2.1%) showed a worsening of seizure frequency. Patients with idiopathic generalized epilepsy such as juvenile myoclonic epilepsy showed satisfactory results. Many good responders were also patients with stroke or brain tumor. The number of concomitant AEDs used demonstrated a more distinctive feature. Monotherapy without any other AEDs was used in 20 patients. LTG was used as an add-on with 1 concomitant AED in 59 patients (42.1%) and as an add-on with 2 concomitant AEDs in 37 patients (26.4%). Thus, a large number of patients (68.6%) underwent early add-on treatment. LTG as an add-on in concert with concomitant AEDs contributed to the excellent results in terms of seizure reduction observed in this study. LTG administration requires established titration, particularly to prevent drug eruption. Over 60% of the patients were treated by slower titration than that used in the established titration method. However, seizure freedom was accomplished within 1-5 weeks from the beginning of LTG treatment with doses much lower than 200 mg/day, which indicated the effectiveness of low-dose LTG in the early phase of treatment. The average maintenance dose was 162.7 mg/day; however, half of the patients maintained their dose at more than 200 mg/day. The continuation rate was 77.2%. The main reasons for withdrawal were dissatisfaction with drug effectiveness and drug eruption. However, the incidence of drug eruption was only in 15 out of 281 (5.3%) patients, which is similar to previously reported rates. Therefore, LTG is an effective and safe AED. Moreover, it is a promising drug for promoting a paradigm shift towards newer AEDs. LTG administration as a first add-on AED is strongly recommended to obtain excellent results and to maintain good compliance with the epilepsy treatment course.

[]An adult case of mumps-associated encephalitis/encephalopathy successfully treated with steroid pulse therapy].

A 32-year-old-immunologically healthy woman suffered from mumps. A few days later, she was brought to our hospital because of generalized convulsions. On arrival, she developed a decorticate posture. Anti-mumps virus antibodies were detected in her serum. Elevated protein levels without pleocytosis were observed in her cerebrospinal fluid. On the basis of a diagnosis of mumps-associated encephalitis/encephalopathy, steroid pulse therapy was administered, which improve her disturbance of consciousness. She exhibited akinetic mutism, which was followed by deterioration of the frontal lobe. Single-photon emission computed tomography demonstrated decreased regional cerebral blood flow in the bilateral frontal regions. Therefore, she was suspected with frontal lobe dysfunction associated with the lesion, including the thalamus and/or brain stem. We consider that the encephalitis/encephalopathy present in this case was caused by a reversible autoimmune process triggered by mumps virus infection.

[Clinical efficacy of the novel antiepileptic agent levetiracetam: evaluation in patients with localization-related epilepsy].

In this retrospective study, we evaluated the safety and efficacy of levetiracetam (LEV) as an antiepileptic drug by using data in our hospital database from October 2010, when LEV became available in Japan, through August 2011. Data from patients aged 16 years or more (n=132) with localization-related epilepsy (n=112) and generalized epilepsy (n=19) were reviewed. Among patients with localization-related epilepsy, 53.6% showed a greater than 50% reduction in seizure frequency compared with the pretreatment baseline, and 28.6% of them became seizure free during the treatment period. Adverse events were reported in 27.3% of patients and caused discontinuation of LEV in 10.6%. The most frequent adverse events were somnolence (14.4%), irritability or aggressiveness (6.1%), and depression (4.5%). However, most of the adverse events were of mild to moderate severity. More than 80% of patients continued LEV treatment. The frequency of adverse events and discontinuation rate after LEV treatment were not associated with the starting dose (1,000 mg/day or less). LEV was well tolerated and efficacious as an adjunctive therapy for localization-related epilepsy.

[A case of cerebral amyloid angiopathy with reversible white matter lesions and multiple cerebral microbleeds].

A 59-year-old woman presented with a 7-year history of headache. She showed no neurological abnormality. T(2) weighted magnetic resonance (MR) images showed a hyperintense signal in the white matter in the bilateral parieto-occipital lobe without abnormal enhancement. A small amount of prednisolone was administered for rheumatoid arthritis. After prednisolone was discontinued, the T(2) weighted images showed an expansion of the hyperintense signal lesions seen in the white matter, and T(2) weighted image showed multiple foci of petechial bleeding in the cortex and subcortex of the bilateral occipital lobe. A brain biopsy specimen from the right occipital lobe revealed deposition of amyloid in the subarachnoidal and cortical vessel walls and transmural infiltration of a few lymphocytes, eosinophils, and giant histiocytes. Subsequently the patient was diagnosed with central nervous system vasculitis associated with cerebral amyloid angiopathy (CAA). After 5 months, the T(2) weighted images showed a remarkable regression of the hyperintense signal lesions in the white matter of the bilateral parieto-occipital lobe without the administration of any maintenance immunosuppressive agents. However, T(2) weighted image showed an increase of multiple cortico-subcortical foci of petechial bleeding. Her headache did not improve during the illness. Thus, we should consider the diagnosis of CAA when patients present with reversible white matter lesions and multiple cerebral microbleeds simultaneously.

[A case report of primary central nervous system lymphoma preceded by cerebral and cerebellar lesion diminishing spontaneously: consideration of two brain biopsy at the onset and after two years].

A 57-year-old man suffered a generalized seizure. Brain MRI showed a Gadolinium (Gd) enhanced lesion with massive edema in the left frontal lobe. He received in a brain biopsy a diagnosis of ganglioglioma, probable. After two weeks from the biopsy, brain MRI showed spontaneous remmision of the lesion. Eighteen months after his seizure, a follow-up brain MRI showed a new lesion in the left cerebellar peduncle. However, the lesion also improved spontaneously. After 2 years from the onset, a follow-up examination showed a new lesion in the corpus callosum. At that time even though high dose corticosteroid was given with the diagnosis of multiple sclerosis, the lesion enlarged progressively and uveitis occurred at the same time. He received in the second biopsy a diagnosis of diffuse large B cell lymphoma We report a case of primary central nervous system lymphoma preceded by cerebral and cerebellar lesion diminishing spontaneously, with consideration of two brain biopsy at the onset and after two years.

A randomized clinical study of tea catechin inhalation effects on methicillin-resistant Staphylococcus aureus in disabled elderly patients.

OBJECTIVES: To evaluate the effects of tea catechin inhalation on methicillin-resistant Staphylococcus aureus (MRSA) in disabled elderly patients. DESIGN: Seven days, randomized, prospective study. SETTING: Three hospitals in Japan. PARTICIPANTS: Seventy-two patients aged 78 +/- 11 years (mean age +/- standard deviation) with cerebrovascular diseases, classified as disabled according to the activity of daily living and were either bedridden or required assistance for standing, and showing presence of MRSA in sputum. INTERVENTIONS: Inhalation of 2 mL tea catechin extract solution along with saline (3.7 mg/mL catechins, 43% of catechins are composed of epigallocatechin gallate), or saline alone, 3 times daily using a handheld nebulizer for 7 days. MEASUREMENTS: The endpoint of efficacy was the reduction rates of MRSA in sputum. The safety measure was the adverse events observed during the 7 days of inhalation. RESULTS: The reduction rates calculated as the summation of decrease and disappearance of MRSA in sputum at 7 days were 47% (17 of 36 patients) in the catechin group and 15% (5 of 33 patients) in the control group; the difference in the reduction rates between the 2 groups was statistically significant (P = .014). The disappearance rate of MRSA in sputum was higher in the catechin group (31%; 11 patients) when compared with the control group (12%; 4 patients), however the difference in the disappearance rate between the 2 groups was not statistically significant (P = .091). No adverse events, such as respiratory tract obstruction, allergic bronchial spasm, or skin eruption, including laboratory changes, were observed during the study. CONCLUSION: The catechin inhalation appeared to reduce the MRSA count in sputum. However, the application of tea catechin inhalation as a supplementary treatment for controlling MRSA infection remains controversial.