RESUMEN
PURPOSE: Episodic nocturnal hypercapnia (eNH) in transcutaneous carbon dioxide pressure (PtcCO2) corresponding to rapid eye movement sleep hypoventilation is a useful biomarker for detecting nocturnal hypoventilation. However, the relationship between eNH and neurodegenerative diseases with sleep-related breathing disorders (SRBDs) is unknown. The aim of this study was to evaluate the relationship between eNH and nocturnal hypoventilation in neurodegenerative diseases. METHODS: Patients with neurodegenerative diseases, including amyotrophic lateral sclerosis (ALS), multiple system atrophy (MSA), Parkinson's disease, progressive supranuclear palsy, corticobasal syndrome, and idiopathic normal pressure hydrocephalus, were enrolled and received overnight PtcCO2 monitoring. The patients were divided into groups for eNH and sleep-associated hypoventilation (SH) prevalence analysis: A (ALS), B (MSA), and C (others). RESULTS: Among 110 patients, twenty-three (21%) and 10 (9%) of the patients met eNH and SH criteria, respectively. eNH and SH were significantly more frequent in groups A and B than in C. The prevalence of SH in the patients with eNH was 39% whereas most of patients with SH (90%) presented with eNH. Among patients with daytime carbon dioxide pressure in arterial blood ≤ 45 mmHg, eNH frequency was 13%, whereas none of the patients met SH criteria. The frequency of noninvasive positive pressure ventilation after PtcCO2 monitoring was significantly higher in those with than without eNH. CONCLUSIONS: eNH is common in patients with MSA and ALS who present with SRBD. eNH with overnight PtcCO2 monitoring is a useful biomarker to detect hypoventilation among neurodegenerative diseases with different SRBD mechanisms.
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Esclerosis Amiotrófica Lateral , Enfermedades Neurodegenerativas , Humanos , Hipercapnia/diagnóstico , Hipercapnia/epidemiología , Hipoventilación/diagnóstico , Dióxido de Carbono , Esclerosis Amiotrófica Lateral/diagnóstico , Esclerosis Amiotrófica Lateral/epidemiología , Enfermedades Neurodegenerativas/diagnóstico , Enfermedades Neurodegenerativas/epidemiología , BiomarcadoresRESUMEN
BACKGROUND AND PURPOSE: Recent studies have demonstrated that endovascular reperfusion therapy improves clinical outcomes at 90 days after ischemic stroke. However, the effects on long-term outcomes are not well known. We hypothesized that successful reperfusion might be associated with long-term improvement beyond 90 days after endovascular therapy. To assess the long-term effects beyond 90 days, we analyzed the association of successful reperfusion with a temporal change in modified Rankin Scale (mRS) score from 90 days to 1 year after endovascular therapy. METHODS: We retrospectively analyzed a database of consecutive patients with acute ischemic stroke who received endovascular therapy between April 2006 and March 2016 at 4 centers. We compared the incidences of improvement and deterioration in patients with successful reperfusion (i.e., modified thrombolysis in cerebral infarction score of 2b or 3) with those in patients with unsuccessful reperfusion. We defined improvement and deterioration as decrease and increase on the mRS score by 1 point or more from 90 days to 1 year after endovascular therapy respectively. RESULTS: A total of 268 patients were included in the current study. The rate of patients with improvement tended to be higher in patients with successful reperfusion than in patients with unsuccessful reperfusion (20% [34/167 patients] vs. 12% [12/101], p = 0.07). The rate of patients with deterioration was lower in patients with successful reperfusion than in patients with unsuccessful reperfusion (25% [42/167] vs. 42% [42/101], p < 0.01). After adjustment for confounders, successful reperfusion was associated with improvement (adjusted OR 2.65; 95% CI 1.23-5.73; p < 0.05) and deterioration (adjusted OR 0.33; 95% CI 0.18-0.62; p < 0.01), independent of the 90-day mRS score. CONCLUSIONS: Successful reperfusion has further beneficial legacy effects on long-term outcomes beyond 90 days after stroke.
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Isquemia Encefálica/terapia , Procedimientos Endovasculares , Reperfusión/métodos , Accidente Cerebrovascular/terapia , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/fisiopatología , Bases de Datos Factuales , Evaluación de la Discapacidad , Procedimientos Endovasculares/efectos adversos , Femenino , Humanos , Japón , Masculino , Recuperación de la Función , Reperfusión/efectos adversos , Estudios Retrospectivos , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/fisiopatología , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVES: The management of atrial fibrillation and deep venous thrombosis has evolved with the development of direct oral anticoagulants (DOAC), and oral anticoagulant (OAC) might influence the development or clinical course in both ischemic and hemorrhagic stroke. However, detailed data on the differences between the effects of the prior prescription of warfarin and DOAC on the clinical characteristics, neuroradiologic findings, and outcome of stroke are limited. DESIGN: The prospective analysis of stroke patients taking anticoagulants (PASTA) registry study is an observational, multicenter, prospective registry of stroke (ischemic stroke, transient ischemic attack, and intracerebral hemorrhage) patients receiving OAC in Japan. This study is designed to collect data on clinical background characteristics, drug adherence, drug dosage, neurological severity at admission and discharge, infarct or hematoma size, acute therapy including recanalization therapy or reverse drug therapy, and timing of OAC re-initiation. Patient enrollment started in April 2016 and the target patient number is 1000 patients. CONCLUSIONS: The PASTA prospective registry should identify the status of stroke patients taking OAC in the current clinical practice in Japan.
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Anticoagulantes/administración & dosificación , Fibrilación Atrial/tratamiento farmacológico , Isquemia Encefálica/terapia , Hemorragia Cerebral/terapia , Proyectos de Investigación , Accidente Cerebrovascular/terapia , Trombosis de la Vena/tratamiento farmacológico , Administración Oral , Anciano , Anticoagulantes/efectos adversos , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/epidemiología , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/epidemiología , Hemorragia Cerebral/diagnóstico , Hemorragia Cerebral/epidemiología , Femenino , Adhesión a Directriz , Humanos , Prescripción Inadecuada , Japón/epidemiología , Masculino , Guías de Práctica Clínica como Asunto , Pautas de la Práctica en Medicina , Estudios Prospectivos , Sistema de Registros , Medición de Riesgo , Factores de Riesgo , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/epidemiología , Factores de Tiempo , Resultado del Tratamiento , Trombosis de la Vena/diagnóstico , Trombosis de la Vena/epidemiologíaRESUMEN
BACKGROUND: Clinical outcomes after successful endovascular therapy in patients with acute ischemic stroke are associated with several factors including onset-to-reperfusion time (ORT), the National Institute of Health Stroke Scale (NIHSS) score, and the Alberta Stroke Program Early CT Score (ASPECTS). The NIHSS-time score, calculated as follows: [NIHSS score] × [onset-to-treatment time (h)] or [NIHSS score] × [ORT (h)], has been reported to predict clinical outcomes after intravenous recombinant tissue plasminogen activator therapy and endovascular therapy for acute stroke. The objective of the current study was to assess whether the combination of the ASPECTS and the ORT can predict the outcomes after endovascular therapy. METHODS: The charts of 117 consecutive ischemic stroke patients with successful reperfusion after endovascular therapy were retrospectively reviewed. We analyzed the association of ORT, ASPECTS, and ASPECTS-time score with clinical outcome. ASPECTS-time score was calculated as follows: [11 - ASPECTS] × [ORT (h)]. RESULTS: Rates of good outcome for patients with ASPECTS-time scores of tertile values, scores 5.67 or less, scores greater than 5.67 to 10.40 or less, and scores greater than 10.40, were 66.7%, 56.4%, and 33.3%, respectively (P < .05). Ordinal logistic regression analysis showed that the ASPECTS-time score (per category increase) was an independent predictor for better outcome (common odds ratio: .374; 95% confidence interval: .150-0.930; P < .05). CONCLUSIONS: A lower ASPECTS-time score may predict better clinical outcomes after endovascular treatment.
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Isquemia Encefálica/diagnóstico por imagen , Isquemia Encefálica/terapia , Procedimientos Endovasculares , Accidente Cerebrovascular/diagnóstico por imagen , Accidente Cerebrovascular/terapia , Tomografía Computarizada por Rayos X , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/fisiopatología , Evaluación de la Discapacidad , Procedimientos Endovasculares/efectos adversos , Femenino , Fibrinolíticos/administración & dosificación , Humanos , Infusiones Intravenosas , Japón , Modelos Logísticos , Masculino , Análisis Multivariante , Oportunidad Relativa , Valor Predictivo de las Pruebas , Recuperación de la Función , Estudios Retrospectivos , Accidente Cerebrovascular/fisiopatología , Terapia Trombolítica , Factores de Tiempo , Activador de Tejido Plasminógeno/administración & dosificación , Resultado del TratamientoRESUMEN
BACKGROUND: Outcomes after successful endovascular therapy in acute ischemic stroke are associated with onset-to-reperfusion time (ORT) and the National Institutes of Health Stroke Scale (NIHSS) score. In intravenous recombinant tissue plasminogen activator therapy, the NIHSS-time score, calculated by multiplying onset-to-treatment time with the NIHSS score, has been shown to predict clinical outcomes. In this study, we assessed whether a similar combination of the ORT and the NIHSS score can be applied to predict the outcomes after endovascular therapy. METHODS: We retrospectively reviewed the charts of 128 consecutive ischemic stroke patients with successful reperfusion after endovascular therapy. We analyzed the association of the ORT, the NIHSS score, and the NIHSS-time score with good outcome (modified Rankin Scale score ≤ 2 at 3 months). RESULTS: Good outcome rates for patients with NIHSS-time scores of 84.7 or lower, scores higher than 84.7 up to 127.5 or lower, and scores higher than 127.5 were 72.1%, 44.2%, and 14.3%, respectively (P < .01). Multivariate logistic regression analysis revealed that the NIHSS-time score was an independent predictor of good outcomes (odds ratio, .372; 95% confidence interval, .175-.789) after adjusting for age, sex, internal carotid artery occlusion, plasma glucose level, ORT, and NIHSS score. CONCLUSIONS: The NIHSS-time score can predict good clinical outcomes after endovascular treatment.
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Isquemia Encefálica/terapia , Técnicas de Apoyo para la Decisión , Procedimientos Endovasculares , Accidente Cerebrovascular/terapia , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/fisiopatología , Evaluación de la Discapacidad , Femenino , Humanos , Japón , Modelos Logísticos , Masculino , Análisis Multivariante , Oportunidad Relativa , Valor Predictivo de las Pruebas , Recuperación de la Función , Estudios Retrospectivos , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/fisiopatología , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: Approximately 10 years have passed since intravenous (IV) recombinant tissue plasminogen activator therapy was approved in Japan. The aim of this retrospective study was to identify the effectiveness and safety of IV alteplase therapy with the Japanese original dose around Hiroshima via consideration of the patients' backgrounds, examination findings, and outcomes. METHODS: All consecutive patients with ischemic stroke who received IV alteplase therapy between October 2005 and October 2010 were registered. RESULTS: Four hundred twenty-nine patients with ischemic stroke (172 female [40.1%], mean age 73.7 ± 11.8 years) were registered. The proportion of patients over 75 years old was 51.5% (221 patients). The median National Institutes of Health Stroke Scale (NIHSS) scores at admission were 13 (interquartile range, 9-19), and the NIHSS scores 24 hours after alteplase infusion were 8 (interquartile range, 3-15). The proportion of intracerebral hemorrhage within the initial 36 hours was 20.2% (86 patients). After the multivariate regression analysis, a history of hypertension (odds ratio = 4.14; 95% confidence interval, 1.32-14.79; P = .01) and no recanalization (odds ratio = 10.10; 95% confidence interval, 3.03-39.33; P < .0001) were independently associated with a modified Rankin Scale (mRS) score of 2 or higher at 3 months. Patients over 75 years old were not significantly associated with an intracerebral hemorrhage within the initial 36 hours and an mRS score of 2 or higher at 3 months. CONCLUSIONS: The results of our study demonstrated that IV alteplase therapy with the Japanese original dose was effective and exhibited a safety profile similar to other studies. Moreover, we should not hesitate to IV alteplase therapy simply because of advanced age.
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Isquemia Encefálica/tratamiento farmacológico , Fibrinolíticos/uso terapéutico , Accidente Cerebrovascular/tratamiento farmacológico , Terapia Trombolítica/efectos adversos , Activador de Tejido Plasminógeno/uso terapéutico , Anciano , Anciano de 80 o más Años , Femenino , Fibrinolíticos/administración & dosificación , Fibrinolíticos/efectos adversos , Humanos , Japón , Masculino , Persona de Mediana Edad , Sistema de Registros , Estudios Retrospectivos , Activador de Tejido Plasminógeno/administración & dosificación , Activador de Tejido Plasminógeno/efectos adversos , Resultado del TratamientoRESUMEN
BACKGROUND: We describe the "triple balloon protection technique" (TBPT) using the Mo.Ma Ultra in combination with the Carotid GuardWire during carotid artery stenting (CAS). This technique is expected to prevent distal embolism to the internal and external carotid arteries, and is suitable for East Asians in whom the origin of the superior thyroid artery is lower than that in Caucasians. METHODS: From December 2012 to May 2013, 11 patients underwent CAS using TBPT in our center. RESULTS: Procedural success was achieved in all patients. Complete flow blockade by angiography could not be obtained in 8 patients (72.7%) by proximal occlusion using the Mo.Ma Ultra only. Complete angiographic flow blockade was obtained in all patients by TBPT. No major adverse cardiovascular events, including stroke, myocardial infarction, or death because of any cause, occurred within 30 days. CONCLUSIONS: The use of TBPT for CAS may be effective for preventing distal embolisms, especially for East Asians.
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Oclusión con Balón/instrumentación , Estenosis Carotídea/terapia , Procedimientos Endovasculares/instrumentación , Stents , Pueblo Asiatico , Oclusión con Balón/métodos , Estenosis Carotídea/cirugía , Angiografía Cerebral , Circulación Coronaria , Procedimientos Endovasculares/métodos , Humanos , Resultado del TratamientoRESUMEN
BACKGROUND: The hyperintense vessel sign (HVS) on fluid-attenuated inversion recovery images can frequently be detected in patients with acute cerebral infarction attributable to large artery stenosis or occlusion. The prognostic values and clinical characteristics of HVS remain to be elucidated. The aim of this study was to evaluate the association of HVS with ischemic lesions and severity of neurologic deficit. METHODS: A total of 96 consecutive acute ischemic stroke patients (54 women, median age 76.5 [range 39-97] years), who had symptomatic severe stenosis or occlusion in the proximal middle cerebral artery that was detected with magnetic resonance angiography within 24 hours of onset, were enrolled. The extent of HVS was graded by a systematic quantitative scoring system (the HVS distribution score) based on Alberta Stroke Program Early Computed Tomographic Score. RESULTS: An HVS was detected in 89 patients (93%) at admission, and the patients who displayed wider HVS distribution scores exhibited more severe neurologic deficits at admission (P<.05). The follow-up magnetic resonance imaging, which was obtained in 79 patients (82%), was performed an average of 13 days. The association between HVS distribution score and final ischemic lesions was strongly observed (n=67, P<.05) but not in the patients with intravenous thrombolysis (n=12, P=.06). CONCLUSIONS: Although the distribution of HVS reflected final ischemic lesion, this association might not apply to the patients with the thrombolysis treatment. The interpretation of HVS distribution score with acute ischemic stroke patients should be discussed dependent on thrombolysis.
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Isquemia Encefálica/diagnóstico , Encéfalo/patología , Accidente Cerebrovascular/diagnóstico , Adulto , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/tratamiento farmacológico , Isquemia Encefálica/patología , Femenino , Fibrinolíticos/uso terapéutico , Humanos , Angiografía por Resonancia Magnética , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Pronóstico , Índice de Severidad de la Enfermedad , Accidente Cerebrovascular/tratamiento farmacológico , Accidente Cerebrovascular/patología , Terapia TrombolíticaRESUMEN
An 87-year-old woman was admitted with acute onset of disturbed consciousness. On neurological examination, both pupils were dilated and non-reactive to light. Decerebrate rigidity was present. Babinski testing was positive. CTA suggested an isolated left P1 segment occlusion. The P2 segment was supplied from the left internal carotid artery via the posterior communicating artery. MRI showed bilateral paramedian thalamic infarctions. Because occlusion of the artery of Percheron was suspected, intravenous thrombolysis was performed. Digital subtraction angiography (DSA) revealed occlusion of the left P1 segment and spontaneous recanalization before endovascular treatment. Her consciousness improved immediately. When acute bilateral thalamic infarction suggests top of the basilar artery syndrome but no basilar artery occlusion is found, occlusion of the artery of Percheron should be considered. Thrombectomy of the affected P1 segment may be needed.
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Arteriopatías Oclusivas , Insuficiencia Vertebrobasilar , Humanos , Femenino , Anciano de 80 o más Años , Infarto Cerebral/diagnóstico por imagen , Infarto Cerebral/etiología , Imagen por Resonancia Magnética , Arteria Basilar , TrombectomíaRESUMEN
Giant cell arteritis (GCA) occasionally presents with ischaemic stroke. Generally, symptoms related to GCA or elevated levels of inflammation markers would be a clue for the diagnosis of GCA. However, we encountered a rare case of GCA that presented with recurrent cerebellar infarctions without symptoms related to GCA (headache, fever, or jaw claudication). Furthermore, C-reactive protein levels, measured at the time of two of the stroke attacks, were within the normal range. On physical examination, the temporal arteries were prominent and weakly pulsatile. Temporal artery ultrasonography showed halo signs, and temporal artery biopsy revealed GCA. To our knowledge, this is the first case of GCA presenting with recurrent ischaemic stroke lacking GCA features but diagnosed before death. Considering this case-based review, we suggest that GCA may have been missed in elderly patients with ischaemic stroke, especially in those with posterior circulation infarction. Therefore, physical examination of the temporal arteries, temporal artery ultrasonography, and vessel wall magnetic resonance imaging may be useful in those patients.
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Isquemia Encefálica , Arteritis de Células Gigantes , Accidente Cerebrovascular Isquémico , Accidente Cerebrovascular , Anciano , Isquemia Encefálica/complicaciones , Arteritis de Células Gigantes/complicaciones , Arteritis de Células Gigantes/diagnóstico , Arteritis de Células Gigantes/patología , Humanos , Infarto/complicacionesRESUMEN
Associated factors of the Myasthenia Gravis Activities of Daily Living (MG-ADL) score were investigated in 55 patients who had had generalized MG for more than 5 years. In multivariate analysis, correlates of the MG-ADL score at the last follow-up were the total number of fast-acting treatments (FTs) (standardized regression coefficient 0.617ï¼P < 0.001) and Myasthenia Gravis Foundation of America (MGFA) classification (standardized regression coefficient 0.227ï¼P = 0.032) (F = 32.7ï¼P < 0.001). In patients with a score of 5 or more on MG-ADL at the last follow-up, tendency as follows were seen: 1) early-onset (P = 0.002), 2) longer duration (P = 0.014), 3) high frequency of MGFA classification V (P = 0.017), 4) high frequency of the total number of FTs (P < 0.001), and 5) higher dose of prednisolone at the last follow-up (P = 0.003). MGFA V, early-onset without depending on E-L-T classification, or difficulty of reduction for high doses of prednisolone can be the target of novel treatment for MG, and future prospective study will be expected.
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Actividades Cotidianas , Miastenia Gravis , Humanos , Estudios Prospectivos , Miastenia Gravis/diagnóstico , Miastenia Gravis/tratamiento farmacológico , Prednisolona , PacientesRESUMEN
Central nervous system methotrexate-associated lymphoproliferative disorder (CNS-MTX-LPD) is rare, but its spontaneous regression has been observed in some patients after withdrawal of agents. We herein report three cases of primary CNS-MTX-LPD that received oral MTX for rheumatoid arthritis. Epstein-Barr virus and oligoclonal bands (OCBs) were positive, while proton magnetic resonance spectroscopy (1H-MRS) showed an elevated lipid peak and slightly elevated choline/N-acetylaspartate ratio in common. After MTX withdrawal, brain lesions showed spontaneous regression in all cases. Our patient's 1H-MRS findings and OCBs may reflect a non-monoclonal lymphoproliferative histology as benign-type lesions in CNS-MTX-LPD.
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Antirreumáticos , Infecciones por Virus de Epstein-Barr , Trastornos Linfoproliferativos , Humanos , Metotrexato/efectos adversos , Bandas Oligoclonales/uso terapéutico , Antirreumáticos/uso terapéutico , Infecciones por Virus de Epstein-Barr/patología , Herpesvirus Humano 4 , Trastornos Linfoproliferativos/inducido químicamente , Trastornos Linfoproliferativos/diagnóstico por imagen , Trastornos Linfoproliferativos/tratamiento farmacológico , Pronóstico , Sistema Nervioso Central/patología , Espectroscopía de Resonancia MagnéticaRESUMEN
A 36-year-old man experienced severely impaired consciousness twice after drinking because of hyperammonemia. No abnormal blood tests were found other than ammonia levels. However, magnetic resonance imaging (MRI) showed atrophy of the brain parenchyma. One the second occasion, the patient suffered severe impairment of consciousness, and because of seizures and glossoptosis, mechanical ventilation was started. Urea cycle disorders (UCDs) were assumed to be involved. Genetic testing revealed a monoallelic mutation of the carbamoyl phosphate synthase 1 (CPS1) gene. When transient hyperammonemia of unknown cause occurs repeatedly in adults, an active investigation for UCDs should be conducted.
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Enfermedad por Deficiencia de Carbamoil-Fosfato Sintasa I , Hiperamonemia , Trastornos Innatos del Ciclo de la Urea , Adulto , Carbamoil-Fosfato Sintasa (Amoniaco)/genética , Enfermedad por Deficiencia de Carbamoil-Fosfato Sintasa I/complicaciones , Enfermedad por Deficiencia de Carbamoil-Fosfato Sintasa I/genética , Carbamoil Fosfato , Estado de Conciencia , Humanos , Hiperamonemia/complicaciones , Hiperamonemia/diagnóstico , Hiperamonemia/genética , Masculino , Mutación/genética , Trastornos Innatos del Ciclo de la Urea/complicacionesRESUMEN
AIM: We classified acute ischemic stroke patients with cancer according to their causal relations, and attempted to evaluate the clinical characteristics of ischemic stroke associated with cancer. METHODS: This is a retrospective study of all acute ischemic stroke patients admitted to our hospital between January 2006 and March 2009. Among acute ischemic stroke patients, we identified 30 patients with a history of cancer, or who developed cancer within 1 year from their ischemic stroke onset. There were 2 patients excluded from our evaluation because they had undergone extirpation of their cancer more than 5 years before stroke onset, and no recurrence of cancer within 5 years of stroke onset was noted. Finally, 28 patients were enrolled and evaluated in this study. Ischemic stroke was classified based on the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria. In addition, we classified the patients according to their causal relations of ischemic stroke with cancer. RESULTS: The median patient age was 74 years (range, 56 to 91 years); 68% of patients were men. Of these, 8 (29%) were classified into an ischemic stroke related to cancer group. There was a higher prevalence of ischemic stroke related to cancer in patients under 75 years old with clinical stage IV cancer (p=0.02). D-dimer tended to be higher in those patients with ischemic stroke related to cancer in this study (p=0.13). CONCLUSION: Ischemic stroke related to cancer was found more frequently in patients under 75 years old with advanced cancer. Additionally, D-dimer tended to be higher in those patients with ischemic stroke related to cancer.
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Infarto Cerebral/complicaciones , Neoplasias/complicaciones , Anciano , Anciano de 80 o más Años , Infarto Cerebral/sangre , Femenino , Productos de Degradación de Fibrina-Fibrinógeno/análisis , Humanos , Masculino , Persona de Mediana EdadRESUMEN
A 76-year-old man with renal cell carcinoma exhibited consciousness disturbance and high fever after two cycles of combination therapy with ipilimumab and nivolumab. His cerebrospinal fluid (CSF) showed a protein concentration of 385 mg/dl, a cell count of 147/mm3, an interleukin-6 concentration of 1,280 pg/ml, and an adenosine deaminase concentration of 24.8 U/l. Contrast-enhanced FLAIR images were notable for diffuse meningeal enhancement. He was diagnosed with meningoencephalitis caused by an immune-related adverse event from immune checkpoint inhibitors (ICIs). His symptoms improved after repeated intravenous methylprednisolone pulse therapy and oral prednisolone. The meningeal enhancement disappeared, and the CSF findings became almost normal. As consciousness levels improved, we observed quadriplegia and peripheral neuropathy with antiganglioside antibodies, which led to a diagnosis of polyradiculoneuropathy. This is a rare case of a patient with overlapping meningoencephalitis and polyradiculo-neuropathy induced by ICIs.
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Ipilimumab/efectos adversos , Neoplasias Renales , Meningoencefalitis , Nivolumab/efectos adversos , Polirradiculoneuropatía , Anciano , Humanos , Masculino , Meningoencefalitis/inducido químicamente , Meningoencefalitis/tratamiento farmacológico , Polirradiculoneuropatía/inducido químicamenteRESUMEN
AIMS: The mainstay of treatment for idiopathic normal-pressure hydrocephalus (iNPH) is spinal fluid shunting. A tap test (TT) is recommended as an indication of shunting. Patients with iNPH are often elderly and have multiple comorbidities affecting the shunting outcome. We investigated the factors affecting TT in patients with iNPH. METHODS: Seventy-five patients with iNPH were admitted to our department for a TT from April 2010 to May 2021. The patients were divided into a responsive group and an unresponsive group according to the clinical outcomes after TT on the Timed Up and Go Test (TUG), Mini-Mental State Examination (MMSE), or iNPH grading scale. Factors affecting the TT were compared between the responders and nonresponders. RESULTS: There were 38 patients (50.7%) in the TT responder group, and the prevalence of improvement was 82.9% in the TUG, 27.6% in the MMSE, and 76.3% in the iNPH grading scale. There were no significant differences in the vascular risk factors between the two groups. The prevalence of lumbar spondylosis, compression fracture, severe periventricular hyperintensity, deep and subcortical white matter hyperintensity (DSWMH), and old cerebral infarcts was significantly higher among the TT nonresponders. The logistic regression analysis showed that severe DSWMH and lumbar spondylosis were associated with a TT nonresponse (p < 0.001 and p = 0.003, respectively). Shunting was performed in 22 patients, 19 of whom were TT responders. CONCLUSION: Severe DSWMH and lumbar spondylosis were associated with a poor response to the TT in iNPH patients. We should consider risk factors when selecting candidates for shunt surgery.
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Hidrocéfalo Normotenso , Equilibrio Postural , Anciano , Derivaciones del Líquido Cefalorraquídeo , Humanos , Hidrocéfalo Normotenso/epidemiología , Hidrocéfalo Normotenso/cirugía , Estudios de Tiempo y MovimientoRESUMEN
Objective: We report a case of reversible cerebral vasoconstriction syndrome (RCVS) that occurred during early pregnancy and improved by endovascular therapy (EVT). Case Presentation: A 30-year-old Japanese woman at 8 weeks' gestation presented with sudden occipital headache followed by left hemiparesis and convulsion. MRI on admission revealed acute infarction in the distribution of the right posterior cerebral artery (PCA), and MRA demonstrated multi-segmental vasoconstrictions in the posterior circulation. Since the episode and image findings were suggestive of RCVS and the patient was in the organogenesis period, intravenous magnesium sulfate was administered as a vasodilator. Her level of consciousness improved temporarily; however, she suddenly fell into a stupor on day 4 of the illness. Emergency MRI demonstrated a fresh infarction in the left side of pons, and the poorer visualization of the posterior circulation. We proposed selective intra-arterial infusion of nicardipine 1 mg over 1 minute through an indwelling microcatheter in the middle of the basilar artery. The left superior cerebellar artery (SCA) and P1 blood flow improved after the procedure. Her symptoms improved gradually, and follow-up MRA performed on day 15 was almost normal. Hence, we established a definite diagnosis of RCVS. She was discharged to recovery phase rehabilitation hospital with modified Rankin Scale 4 and National Institute of Health Stroke Scale (NIHSS) 5. Conclusion: RCVS can occur in early pregnancy period, and EVT is a potential therapeutic option for RCVS in this condition.
RESUMEN
BACKGROUND: We experienced two cases of ischemic stroke resulting from carotid artery occlusion associated with acute type A aortic dissection (ATAAD), in which carotid artery stenting before the surgery for ATAAD resulted in good clinical outcomes.Case 1 description: A 63-year-old woman was hospitalized for conscious disturbance, right hemiparesis, and total aphasia. Computed tomography of the head showed no abnormal findings. Computed tomography angiography showed ATAAD and bilateral common carotid artery occlusion. Surgery was not indicated for ATAAD because of a poor prognosis of ischemic stroke. However, carotid artery stenting of the left common carotid artery occlusion was successfully performed, and her neurological findings improved. The patient underwent hemiarch replacement for ATAAD on the day after carotid artery stenting. Her final modified Rankin Scale was 1. Case 2 Description: A 57-year-old woman was hospitalized for mild left hemiparesis. Magnetic resonance imaging showed right watershed infarction and right common carotid artery occlusion. Computed tomography angiography showed ATAAD. After hospitalization, conscious disturbance appeared and left hemiparesis worsened. Ischemic stroke indicated a poor prognosis for revascularization by surgery for ATAAD. Thus, carotid artery stenting of the right common carotid artery occlusion was performed. The patient's neurological findings improved and she underwent hemiarch replacement for ATAAD at 19 days after carotid artery stenting. Her final modified Rankin Scale was 1. CONCLUSIONS: In the present cases, although ischemic stroke was serious and precluded surgical indication for ATAAD, carotid artery stenting before surgery for ATAAD resulted in good clinical outcomes. Performing carotid artery stenting before surgery for ATAAD is challenging but achievable, and is a valid treatment option depending on the individual cases.
Asunto(s)
Disección Aórtica , Arteriopatías Oclusivas , Enfermedades de las Arterias Carótidas , Disección Aórtica/complicaciones , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/cirugía , Arterias Carótidas , Femenino , Humanos , Persona de Mediana Edad , StentsRESUMEN
PURPOSE: This study aimed to evaluate the risk factors, etiology, and outcomes of ischemic stroke (IS) in Japanese young adults. METHODS: This was a prospective multicenter study. We enrolled patients aged 16 to 55 years with IS within seven days of the onset of symptoms. We assessed the demographic data, risk factors, stroke etiology, and outcome at discharge. The clinical characteristics were compared between sexes and among age groups. RESULTS: We prospectively enrolled 519 patients (median age, 48 years: 139 females). The mean National Institute of Health Stroke Scale score was 3.6 ± 0.2. The most common risk factors were hypertension (HT) (55%), dyslipidemia (DL) (47%), and current smoking (42%). Body mass index, incidence of current smoking, and heavy alcohol consumption were higher in males. The prevalence of current smoking, HT, DL, and diabetes mellitus increased with aging. The most common etiologic subgroup of IS was small vessel disease (145/510, 28%). Intracranial arterial dissection (IAD) was the most common among the other determined causes (56/115, 49%). The outcome at discharge was relatively good (mRS 0-1, 71.7%); however, poor outcome (mRS ≥ 4) was observed at an incidence of 9.5%. CONCLUSIONS: Most young adults with IS had modifiable risk factors, of which prevalence increased with age. This emphasizes lifestyle improvement to prevent IS in the young population. Furthermore, we indicated that the incidence rate of IAD was high among the other determined causes.
Asunto(s)
Isquemia Encefálica , Accidente Cerebrovascular Isquémico , Accidente Cerebrovascular , Adolescente , Adulto , Isquemia Encefálica/epidemiología , Femenino , Humanos , Japón/epidemiología , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de Riesgo , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/etiología , Adulto JovenRESUMEN
OBJECTIVE: To describe our initial experience with the Versi Retriever for mechanical thrombectomy in patients with acute ischemic stroke. METHODS: This study is a single-center, single-arm, first-in-man registry under institutional review board control to evaluate the efficacy and safety of the new stent retriever, the Versi Retriever. Patients with acute ischemic stroke were consecutively enrolled between September and November 2017. The clinical and procedural data were retrospectively analyzed. The angiographic result after the procedure was self-graded based on the Thrombolysis in Cerebral Infarction (TICI) scale by each operator. RESULTS: Eleven patients with a mean age of 69.4 years were treated with the Versi Retriever. Median National Institutes of Health Stroke Scale score on admission was 16 (IQR 10-34). The occluded vessel was located in the anterior circulation in 81.8%. Revascularization rates of TICI 2b-3 and TICI 3 at final angiogram were achieved in 100% and 63.6%, respectively. A favorable functional outcome (modified Rankin Scale 0-2) at 90 days was obtained in 72.7%. No symptomatic intracranial hemorrhage occurred and no procedure-related complication was observed. CONCLUSIONS: Our initial experience suggests that the Versi Retriever is a safe and effective stent retriever for mechanical thrombectomy in patients with acute ischemic stroke. CLINICAL TRIAL REGISTRATION: NCT03366818.