Stroke treatment during the COVID-19 pandemic.

Studies have reported that COVID-19 is associated not only with pneumonia but also with cerebrovascular disease. Consequently, medical personnel involved in treating stroke in the emergency medicine setting have been placed in a situation that requires them to provide treatment while always remaining mindful of the possibility of COVID-19. Here, we describe the current state of stroke treatment during the COVID-19 pandemic. Four patients with stroke and concomitant COVID-19 were treated at our facility. We treated 3 patients with cerebral infarction and 1 patient with cerebral venous sinus thrombosis. All 3 patients with cerebral infarction had a poor outcome. This was attributed in part to the poor general condition of the patients due to concomitant COVID-19, as well as to the severity of the major artery occlusion and cerebral infarction. One patient with cerebral venous sinus thrombosis had a good outcome. Anticoagulant therapy was administered at our hospital and resulted in a stable clinical course. Our hospital has worked to establish an examination and treatment system that enables mechanical thrombectomy to be performed even during the COVID-19 pandemic. We devised a protocol showing the steps to be taken from initial treatment to admission to the cerebral angiography room. Our hospital was able to continue accepting requests for emergency admission thanks to the examination and treatment system we established. Up-to-date information should continue to be collected to create examination and treatment systems.

Feasibility evaluation of transtympanic laser stimulation of the cochlea from the outer ear.

Infrared laser stimulation has been studied as an alternative approach to auditory prostheses. This study evaluated the feasibility of infrared laser stimulation of the cochlea from the outer ear, bypassing the middle ear function. An optic fiber was inserted into the ear canal, and a laser was used to irradiate the cochlea through the tympanic membrane in Mongolian gerbils. A pulsed infrared laser (6.9 mJ/cm2) and clicking sound (70 peak-to-peak equivalent sound pressure level) were presented to the animals. The amplitude of the laser-evoked cochlear response was systematically decreased following insertion of a filter between the tympanic membrane and cochlea; however, the auditory-evoked cochlear response did not decrease. The filter was removed, and the laser-evoked response returned to around the original level. The amplitude ratio and the relative change in response amplitude before and during filter insertion significantly decreased as the absorbance of the infrared filter increased. These results indicate that laser irradiation could bypass the function of the middle ear and directly activate the cochlea. Therefore, laser irradiation from the outer ear is a possible alternative for stimulating the cochlea, circumventing the middle ear.

Cerebral Infarction Due to Aortic Mural Thrombus in a Non-atherosclerotic Ascending Aorta, Detected by Cardiac CT.

Aortic mural thrombus (AMT) in the ascending aorta is a rare source of embolism. Recently, the usefulness of contrast computed tomography (CT) has been reported, and we sought to examine the differences between cardiac CT and CT angiography (CTA). A 58-year-old patient of acute embolic infarction was treated by endovascular thrombectomy. Postoperative cardiac CT revealed the AMT as an embolic source. The lesion was not detected by the CTA performed 2 days before. This is the first case report of AMT to highlight the apparent utility of cardiac CT. Although trans-esophageal echocardiogram (TEE) is still the first choice for routine embolic exploration, cardiac CT may play a role as an alternative tool aimed to detect small size AMT.

Auditory cortical activity elicited by infrared laser irradiation from the outer ear in Mongolian gerbils.

Infrared neural stimulation has been studied for its potential to replace an electrical stimulation of a cochlear implant. No studies, however, revealed how the technic reliably evoke auditory cortical activities. This research investigated the effects of cochlear laser stimulation from the outer ear on auditory cortex using brain imaging of activity-dependent changes in mitochondrial flavoprotein fluorescence signal. An optic fiber was inserted into the gerbil's ear canal to stimulate the lateral side of the cochlea with an infrared laser. Laser stimulation was found to activate the identified primary auditory cortex. In addition, the temporal profile of the laser-evoked responses was comparable to that of the auditory responses. Our results indicate that infrared laser irradiation from the outer ear has the capacity to evoke, and possibly manipulate, the neural activities of the auditory cortex and may substitute for the present cochlear implants in future.

Intracranial growing teratoma syndrome observed at 44 months after initial treatment; a case presentation and literature review.

Intracranial growing teratoma syndrome (iGTS) is rare phenomenon which is observed in non-germinomatous germ cell tumor (NGGCT) after chemotherapy. The clinical features of iGTS are rapidly increasing in size compared with relapse, no elevation of tumor marker in spite of tumor regrowth, multiple cystic lesions in cranial imaging, and histopathologically diagnosed as mature teratoma. Here we present a 14-year-old man with iGTS which was revealed at 44 months after initial chemotherapy. He was diagnosed as pineal immature teratoma by histopathological specimen, and we performed chemotherapy and radiation therapy. After this treatment, we found growing cystic lesion in tumor removal cavity at 26 months after surgery. The histopathological findings showed dermoid cyst in first salvage surgery. Following this result, we observed him without adjuvant chemotherapy. However he had continuous headache, abnormal eye movement at 44 months after initial treatment. Cranial MRI showed regrowing cyst. In second salvage surgery, mature teratoma was demonstrated on histopathological specimen, and we diagnosed as iGTS. Although most reported iGTSs show rapid increasing after initial chemotherapy, few reported cases show regrowth at chronic phase as our case. In long-term follow-up of germ cell tumor, iGTS is important as differential diagnosis.

Auditory-induced visual illusions in rodents measured by spontaneous behavioural response.

When two brief sounds are presented with a short flash of light, we often perceive that the flash blinks twice. This phenomenon, called the "sound-induced flash illusion", has been investigated as an example of how humans finely integrate multisensory information, more specifically, the temporal content of perception. However, it is unclear whether nonhuman animals experience the illusion. Therefore, we investigated whether the Mongolian gerbil, a rodent with relatively good eyesight, experiences this illusion. The novel object recognition (NOR) paradigm was used to evaluate the gerbil's natural (i.e., untrained) capacity for multimodal integration. A light-emitting diode embedded within an object presented time-varying visual stimuli (different flashing patterns). The animals were first familiarised with repetitive single flashes. Then, various sound stimuli were introduced during test trials. An increase in exploration suggested that the animals perceived a flashing pattern differently only when the contradicting sound (double beeps) was presented simultaneously with a single flash. This result shows that the gerbil may experience the sound-induced flash illusion and indicates for the first time that rodents may have the capacity to integrate temporal content of perception in a sophisticated manner as do humans.

[Predictive Factors for Gastrointestinal Bleeding Following Hemorrhagic Stroke: A Hospital-Based Cohort Study].

BACKGROUND AND PURPOSE: Gastrointestinal bleeding is an important complication in the acute phase of hemorrhagic stroke. In this study, we aimed to identify the risk factors for gastrointestinal bleeding in patients with hemorrhagic stroke despite the administration of antiulcer drugs. METHODS: We conducted a retrospective cohort study of our hemorrhagic stroke cases. We analyzed the background factors associated with gastrointestinal bleeding in the study population and their outcomes. RESULTS: The study included 837 patients: 598 with intracerebral hemorrhages and 239 with subarachnoid hemorrhages. Among them, 22 patients developed gastrointestinal bleeding. Intraventricular hemorrhage (P=0.0019) and ongoing oral anticoagulant use (P=0.0177) were significantly associated with gastrointestinal bleeding. Gastrointestinal bleeding was significantly associated with severe disability at discharge (P=0.0333) and number of days of hospitalization (P=0.0190). CONCLUSIONS: The risk factors of poorly controlled gastrointestinal bleeding during the acute phase of hemorrhagic strokes were intraventricular hemorrhage and use of anticoagulant drugs. Patients with a high risk for gastrointestinal bleeding need to be identified and to be given effective prophylactic therapy. (Received October 12, 2017; Accepted March 29, 2018; Published August 1, 2018).

New Prediction Score for Hematoma Expansion and Neurological Deterioration after Spontaneous Intracerebral Hemorrhage: A Hospital-Based Retrospective Cohort Study.

OBJECTIVE: To ensure hematoma expansion and neurological deterioration in the management of acute spontaneous intracerebral hemorrhage, accurate prediction is crucial for initial assessment on admission. We conducted this study to develop a new clinical prediction score using only noncontrast computed tomography image and simply measurable variables. METHODS: This study was a retrospective cohort analysis. The study took place in a single academic medical center in Japan. Development of the prediction score was conducted based on patients who presented between October 2010 and June 2015, using univariate and multivariate logistic regression. We then validated the results in a second cohort between July 2015 and April 2017. The primary outcome was hematoma expansion and the secondary outcome was neurological deterioration up to 14 days after onset. RESULTS: In total, 622 patients were included in the analysis after excluding unsuitable cases. Of these, 457 patients were included in the development cohort and 165 were included in the validation cohort, with 10.8% meeting the criteria for hematoma expansion and 8.8% showing neurological deterioration. In the multivariate analysis, predictors of expansion or deterioration were as hematoma heterogeneity on computed tomography, niveau formation, peripheral edema, hematoma volume of more than 30 mL, and anticoagulant use. We then created the HEAVN score based on the univariate regression coefficients. The C-statistics for the hematoma expansion scores were .81 and .80 in the development and validation cohorts, respectively. Similar results were obtained for neurological deterioration. CONCLUSIONS: The HEAVN score is simple and useful for predicting hematoma expansion and neurological deterioration based on imaging and background data.

Specific Factors to Predict Large-Vessel Occlusion in Acute Stroke Patients.

BACKGROUND: The effectiveness of thrombectomy for acute ischemic stroke has been established, and earlier treatment produces better outcomes. If possible to identify large-vessel occlusion (LVO) at the prehospital phase, eligible patients can be shipped directly to a hospital that can perform thrombectomy. The purpose of this study was to determine factors that are specific to LVO and can be known before hospital arrival. METHODS: The subjects were stroke patients during the period between July 2014 and June 2016, who had a National Institutes of Health Stroke Scale (NIHSS) score of 8 or higher and came to our hospital within 6 hours of onset. These patients were divided into an LVO group and a non-LVO group, and background factors, mode of onset, individual NIHSS item scores, and blood pressure at the time of the visit were retrospectively investigated. The selected factors were compared with LVO prediction scales reported in the past. RESULTS: There were 196 stroke patients who had NIHSS scores of 8 or higher and arrived at the hospital within 6 hours. Of these 196 patients, 56 had LVO. This LVO group included a significantly higher number of patients with the 2 items of atrial fibrillation (odds ratio [OR], 11.5: 95% confidence interval [CI], 4.04-32.9; P < .0001) and systolic blood pressure of 170 mm Hg or lower (OR, 2.99: 95% CI, 1.33-6.71, P = .008). These 2 items predicted LVO equally to existing LVO prediction scales. CONCLUSIONS: The 2 items of atrial fibrillation and systolic blood pressure of 170 mm Hg or lower were significantly correlated with LVO.

[An Extremely Rare Case of Penetrating Head Injury Caused by a Nasal Implant Made of an Ivory Chip and a Review of the Literature].

Although penetrating head injuries are very rare in Japan, an extremely rare case is reported in which an ivory chip, embedded in the subcutaneous tissue by a cosmetic rhinoplasty, penetrated the cranium. A 69-year-old woman with a psychiatric disorder suddenly jumped down from a window and bruised her face. The ivory chip went into her left frontal lobe via the frontal sinus. At surgery, it was completely removed via the nasion. There were no postoperative complications after adequate frontal sinus repair and closure of dura mater with a piece of pericranium. The literature dealing with Japanese penetrating head injuries was also reviewed. (Received May 27, 2015; Accepted December 1, 2015; Published June 1, 2016).