Reduction in Pulse Pressure during Standing Can Distinguish Neurogenic Orthostatic Hypotension.

BACKGROUND: We investigated whether changes in the pulse pressure (PP) reduction ratio during the head-up tilt test (HUTT) can aid in distinguishing neurogenic orthostatic hypotension (OH) from non-neurogenic OH. METHODS: We enrolled consecutive patients with NOH and non-neurogenic OH between January 2015 and October 2018. We compared the Valsalva ratio, the presence or absence of late phase II and IV overshoot, the pressure recovery time, and the PP reduction ratio during HUTT between the two OH groups. RESULTS: The expiratory-inspiratory (E:I) ratio and Valsalva ratio were significantly decreased in the NOH group (p = 0.026, p < 0.001, respectively). The absence of late phase II and phase IV overshoot was more frequent in the NOH group than in the non-neurogenic OH group (p = 0.001, p < 0.001, respectively). The pressure recovery time was significantly prolonged in the NOH group (p < 0.001), which exhibited increases in the PP reduction ratio (1-minimal PP/baseline PP) during the HUTT (p < 0.001). We calculated the cutoff point for the PP reduction ratio during HUTT, which exhibited an area under the receiver operating characteristic curve of 0.766 (0.659-0.840, 95% confidence interval). The cutoff value for the PP reduction ratio during HUTT (0.571) exhibited sensitivity of 0.879 and specificity of 0.516. CONCLUSIONS: Increases in the PP reduction ratio during HUTT may be a meaningful NOH laboratory marker.

A case of NMDAR encephalitis treated in the third trimester - novel arterial spin labeling findings and a review of literature.

Diagnosis and treatment of anti-NMDAR encephalitis during pregnancy are challenging. We report a case of anti-NMDAR encephalitis in a 28-year-old, 24 weeks pregnant woman. Her brain magnetic resonance imaging was normal, but arterial spin labeling (ASL) showed increased cerebral blood flow in the right insula and temporal area. She was successfully treated with emergent cesarean section and immunotherapies including intravenous immunoglobulin, steroids, and rituximab. The newborn was healthy and she recovered fully. Early suspicion and proper management is important in treatment of anti-NMDAR encephalitis during pregnancy. ASL can help diagnosing anti-NMDAR encephalitis during pregnancy.

A Breath-Holding Index Applied to the Internal Carotid Artery Siphon in Transcranial Doppler Studies.

BACKGROUND AND PURPOSE: The breath-holding index (BHI) is a useful method to assess cerebrovascular reactivity. It is calculated based on the mean flow velocities of the middle cerebral artery (MCA) using transcranial Doppler (BHIMCA ). Therefore, it is not feasible in patients with poor temporal windows. This study tested the feasibility of a BHI using the internal carotid artery (ICA) siphon flow velocity (BHIICA ). METHODS: Twenty-four patients (aged 38-79 years) with unilateral or bilateral stenosis of the cervical ICAs were prospectively recruited. The 48 examined bilateral ICAs were divided into three groups according to the stenosis degree: <50%, 50-99%, and occlusion. We investigated the reproducibility of both BHI methods (BHIMCA and BHIICA ), the correlation between the two BHI methods, and the tendency for the BHIs to decrease with increasing degree of cervical ICA stenosis. RESULTS: For the BHIMCA , we found a good reproducibility (intraclass correlation coefficient, rI  > .9) and a significantly decreased BHI with increasing stenosis of the ICA (P = .001). For the BHIICA , good reproducibility was demonstrated (rI  > or ≒ .9), but there was no significant decrease in the BHI related to the increasing degree of ICA stenosis (P = .952). Furthermore, the correlation between the two BHI methods was not robust (kappa coefficient, right .259; left .619). CONCLUSIONS: Our study suggests that the BHIICA is not a feasible alternative method to the BHIMCA.

Subarachnoid Contrast Accumulation and Alberta Stroke Program Early Computed Tomography Score Applied to Contrast Accumulation After Thrombectomy as Predictors of Symptomatic Hemorrhage.

BACKGROUND: Areas of contrast accumulation (CA) are commonly found on routine computed tomography (CT) performed immediately after thrombectomy. In the present study, we investigated the types of CA associated with the different outcomes, including symptomatic intracranial hemorrhage (sICH). METHODS: The present study analyzed the data from 145 patients with anterior circulation stroke who had undergone non-contrast-enhanced conventional CT immediately after thrombectomy. The following variables were investigated: collateral status, failure of recanalization, Alberta stroke program early CT score (ASPECTS) applied to CA lesions and diffusion-weighted imaging infarct lesions, and sICH. RESULTS: Of the 145 patients, 102 (70.3%) had CA lesions. All types of CA (any CA, cortical CA, subarachnoid CA, and CA ASPECTS) were significantly associated with poor outcomes (modified Rankin scale score >2). In particular, subarachnoid CA (odds ratio, 23.994; 95% confidence interval, 4.696-122.589) and CA ASPECTS (odds ratio, 0.550; 95% confidence interval, 0.404-0.750) were independently associated with sICH. Patients with subarachnoid CA had poorer collateral status and a larger final infarct size than those without subarachnoid CA, although the initial National Institutes of Health stroke scale score and recanalization rate were comparable between the 2 groups. A CA ASPECTS of ≤5 predicted sICH with a sensitivity of 66.7% and a specificity of 92.6% (area under the curve, 0.854). CONCLUSIONS: Our data suggest that a subarachnoid CA location and CA ASPECTS are predictors of sICH. In particular, a subarachnoid location of CA might signify damage of the subarachnoid collateral arteries, leading to a larger infarct.

Association of Concomitant Intracranial Atherosclerotic Stenosis with Collateral Status in Patients with Emergent Large Vessel Occlusion.

BACKGROUND: Concomitant atherosclerotic stenoses are commonly encountered in emergent large vessel occlusion. This study attempted to prove whether or not the pattern of atherosclerotic stenosis other than symptomatic occlusion is associated with pretreatment collateral status among patients with emergent large vessel occlusion. METHODS: The study included 115 patients with middle cerebral artery territory infarct within 6 hours of stroke onset who were considered for endovascular revascularization therapy. All patients underwent pretreatment conventional computed tomography angiography using a 128-detector high-definition computed tomography scanner. Based on maximum intensity projection images, ≤50% filling of the occluded territory was considered to indicate poor collaterals, whereas >50% filling was considered to indicate good collaterals. Finding of >50% stenosis on computed tomography angiography was considered significant, and the stenosis patterns were classified into intracranial atherosclerotic stenosis and extracranial atherosclerotic stenosis according to the location of the stenosis. RESULTS: All patients had symptomatic M1 (47.8%), M2 (20.0%), or internal carotid artery (32.2%) occlusion. There were 44 patients with poor collaterals (38.3%) and 71 patients with good collaterals (61.7%). Univariate analysis revealed that poor collateral status was associated with advanced age (≥65 years), hypertension, high National Institutes of Health Stroke Scale score, symptomatic internal carotid artery occlusion, and concomitant atherosclerotic stenosis. Multivariate analysis showed that poor collateral circulation was associated with concomitant intracranial atherosclerotic stenosis and symptomatic internal carotid artery occlusion (vs. a more distal occlusion). CONCLUSIONS: Concomitant intracranial atherosclerotic stenosis other than symptomatic occlusion might be a crucial factor associated with pretreatment collateral status among patients with emergent large vessel occlusion.

Transient Anarthria and Quadriplegia in a Patient with Basilar Artery Hypoplasia and Coincidental Intracranial Lipoma: A Case Report.

Cerebral ischemia may be rarely associated with a hypoplastic vertebrobasilar system. Intracranial lipoma is also a very rare congenital malformation. We report the case of a 52-year-old woman with vertebrobasilar transient ischemic attack associated with basilar artery hypoplasia and coincidental intracranial lipoma. She presented with sudden-onset dizziness, anarthria, and quadriplegia lasting for about 30 min. The patient's initial blood pressure was measured at 200/120 mm Hg. The magnetic resonance and computed tomographic images showed the absence of an acute ischemic lesion in the brain but revealed a hypoplasia of the basilar artery and bilateral V4 vertebral arteries. A lipoma of 11 mm in long diameter was also found in the quadrigeminal cistern and at the superior vermis. The electroencephalography, transthoracic echocardiogram, 24-h Holter monitoring, and transcranial Doppler ultrasonography, including patent foramen ovale study, were all noted as negative. The patient was treated with oral aspirin 100 mg, atorvastatin 10 mg, and antihypertensive medication. She had no symptom recurrence after the treatment. Our case suggests that hypoplasia of the vertebrobasilar arteries can be a predisposing factor for posterior circulation ischemia, especially when additional vascular risk factors coexist.