Primary aldosteronism in patients with acute stroke: prevalence and diagnosis during initial hospitalization.

BACKGROUND: Hypertension is the prime risk factor for stroke, and primary aldosteronism (PA) is the most common cause of secondary hypertension. The prevalence of PA in stroke patients has never been reported. The aim of this study was to elucidate the prevalence of PA. METHODS: A total of 427 consecutive patients with acute stroke were prospectively enrolled for this study. The screening tests were performed at the initial visit and a week after admission by measuring plasma aldosterone concentration and plasma renin activity. The rapid adrenocorticotropic hormone (ACTH) test was performed as the confirmatory test when both screening tests were positive. The primary endpoint was a final diagnosis of PA. RESULTS: The sensitivity of the dual screening system for the diagnosis of PA was 88.2 %, and PA was finally diagnosed in 4.0 % of acute stroke patients and in 4.9 % of stroke patients with a history of hypertension. Patients with PA were less likely to be male and have diabetes, and they had higher blood pressure at the initial visit, lower potassium concentration, and more intracerebral hemorrhage. The rapid ACTH test was performed safely even in acute stroke patients. CONCLUSIONS: The prevalence of PA is not low among acute stroke patients. Efficient screening of PA should be performed particularly for patients with risk factors. TRIAL REGISTRATION: UMIN-CTR; UMIN000011021 . Trial registration date: June 23, 2013 (retrospectively registered).

Simple classification of carotid bifurcation: is it possible to predict twisted carotid artery during carotid endarterectomy?

BACKGROUND: The internal carotid artery (ICA) usually runs posterolaterally to the external carotid artery (ECA), but occasionally we encounter the twisted carotid bifurcation, a variant in which the ICA courses medially to the ECA during carotid endarterectomy (CEA). Prediction of this anomaly in the preoperative evaluation is mandatory, although descriptions in the literature are limited. We reviewed the clinical features of patients who underwent CEA and analyzed preoperative cerebral angiography, especially the anteroposterior (AP) view to determine whether it could be a predictive modality. METHODS: In 58 consecutive CEA cases, we simply classified them into three groups; type 1 (the ICA runs laterally and the ECA runs medially), type 2 (the ICA and ECA run to overlap each other), and type 3 (the ICA runs medially and the ECA runs laterally), based on the findings of AP view of cerebral angiography. We compared the clinical features and intraoperative findings of these groups. RESULTS: Of 58 cases, types 1-3 were 24, 30, and four cases, respectively. Twisted carotid bifurcations were recognized in seven cases (12.4 %), including three cases in type 2 and four in type 3, and all twisted cases were found on the right side. Twisted carotids and right-sided lesion were significantly frequent in type 3, but no statistical differences of coexisting diseases were recognized among the three groups. CEAs of twisted carotid bifurcations were performed successfully with correction of the carotid position in three and as it was in four cases. CONCLUSIONS: Twisted carotid bifurcations were observed during operation in 10 % in type 2 and 100 % in type 3. CEA of twisted carotid bifurcations can be performed safely with or without correction of the carotid position. AP view of cerebral angiography could be useful for preoperative evaluation.

The Examination of Prognostic Factors and Treatment Strategies for Traumatic Cerebrospinal Fluid Leakage.

Introduction This study aimed to determine the optimal timing for surgical intervention and the prognostic factors of cerebrospinal fluid (CSF) leakage. Methods We identified 25 patients with probable CSF leaks from 472 consecutive patients with head trauma. In addition to baseline characteristics and findings on admission, injury severity score (ISS), abbreviated injury score (AIS), and other factors related to CSF leakage were considered. We analyzed the prognostic factors after setting the primary endpoint as the modified Rankin Scale (mRS) at the time of discharge to determine the appropriate timing for surgical intervention. Results Univariate analysis revealed significantly poorer prognoses for elderly patients (p<0.001) and cases with low Glasgow Coma Scale (GCS) levels (p=0.039) and high D-dimer levels (p=0.028), which was consistent with findings from the analyses of all patients with head trauma. We found that multiple traumas (AIS≥3 at two or more sites, p=0.047) and high lactate levels (p=0.043) were poor prognostic factors specific to CSF leakage cases, while a longer time to CSF leakage cessation was also associated with a poorer prognosis (median, six days versus 13 days, p=0.014). An evaluation of the time to closure found that spontaneous cessation occurred within 14 days in most cases. Conclusions Conservative medical treatment is the first choice for most cases of traumatic CSF leakage. Surgical intervention should be considered if leakage does not cease after 14 days post injury. Furthermore, severe multiple injuries and high lactate levels were poor prognostic factors specific to patients with CSF leakage.

[Cryptococcal Meningitis in a Patient with Breast Cancer Receiving Everolimus: A Case of Successful Treatment with Continuous Cerebrospinal Fluid Drainage].

Cryptococcosis is a fungal infection that mainly occurs in immunocompromised patients. We present the first case of cryptococcal meningitis in a patient who was being administered everolimus for breast cancer. Everolimus, a selective inhibitor of mammalian target of rapamycin, is a molecular targeting agent that is administered not only as an immunosuppressive agent, but also as an anticancer therapeutic. A 72-year-old woman with recurrent breast cancer had been receiving everolimus. She was admitted to our hospital with headache and vomiting. Lumbar puncture revealed high opening pressure, and cerebrospinal fluid (CSF) evaluation diagnosed cryptococcal meningitis. She was administered liposomal amphotericin-B, followed by fosfluconazole. Daily lumbar puncture was insufficient to reduce the high intracranial pressure; thus, continuous lumbar drainage was needed to improve her symptoms. The indwelling catheter was replaced regularly to prevent bacterial infection. She was treated successfully with extracorporeal CSF drainage for 86 days and fosfluconazole administration over 17 weeks. The patient recovered fully and was discharged on day 153 of hospitalization. As patients who receive everolimus are potentially immunocompromised hosts, we recommend that the medicine be administered with caution considering opportunistic infections when used in patients with cancer. (Received April 19, 2018; Accepted August 9, 2018; Published November 1, 2018).

Unique Diagnostic Features and Surgical Strategy for Intracranial Carotid Sympathetic Plexus Schwannoma: Case Report and Literature Review.

BACKGROUND: Intracranial carotid sympathetic plexus schwannoma (CSPS) is extremely rare; thus differential diagnostic criteria, optimal surgical strategies, and even a precise definition are lacking. Here we describe a case of CSPS and propose a definition and classification for previously reported cases. CASE DESCRIPTION: A 54-year-old man presented with hypacusis and abducens nerve palsy. Radiologic examinations revealed a well-enhanced mass at the right medial temporal base with erosion of the petrous apex and intact perilesional cortical bone. Preoperative findings, such as spontaneous improvement of diplopia, absence of xerophthalmia or facial palsy, and laterally displaced internal carotid artery (ICA), suggested the atypical origins of the petrous apex schwannoma. The tumor was exposed using the subtemporal extradural approach and completely resected. Intact foramen ovale, rostrolateral displacement of the greater superficial petrosal nerve within the outer membrane of the tumor, eroded petrous apex and carotid canal, superolaterally displaced ICA, and lack of an obvious tumor attachment to any of the suspected nerves suggested that the tumor originated from the carotid sympathetic plexus of the petrous ICA. The patient fully recovered without neurological complications. CONCLUSIONS: Preoperative diagnosis of petrous apex schwannoma is difficult: characteristic findings such as diplopia, hypacusis, and laterally displaced ICA may help. In addition, assessment of the relationship between the tumor and cavernous sinus could be useful in the determination of the surgical approach. Complete resection with good clinical outcome could be expected using Dolenc's approach (type A) and by the middle fossa extradural approach (type B) for intracavernous and extracavernous CSPS, respectively.

Late Seizures after Stroke in Clinical Practice: The Prevalence of Non-convulsive Seizures.

Objective The prevalence of the non-convulsive type of late seizure after stroke is unknown. The aim of the present study was to clarify the characteristics of late seizure in clinical practice, mainly focusing on the prevalence of non-convulsive seizure. Methods A total of 178 consecutive patients who were admitted and diagnosed with late seizure after stroke were retrospectively enrolled, and the data of 127 patients for whom the complete seizure was observed by a bystander were analyzed. Clinical information was obtained from the medical records and nursing notes. Results A non-convulsive seizure was observed in 37 patients (29%). A focal seizure and its secondary generalization accounted for 79% of the seizure types. Status epilepticus was observed in 60 patients (47%), including 11 patients (9%) without convulsion. The patients with non-convulsive seizures were significantly younger than those with convulsive seizures, but there were no other significant differences between the two groups with respect to sex, classification or the lesion of stroke. Conclusion There was a high rate of non-convulsive seizures in patients with late seizure after stroke. A non-convulsive seizure may be caused by any type or location of preceding stroke. More attention is needed in the differential diagnosis of neurological deterioration after stroke.

A chronic encapsulated intracerebral hematoma mimicking a brain tumor: Findings on arterial spin labeling of MRI.

BACKGROUND: Intracerebral hematoma usually resolves spontaneously. Chronic encapsulated intracerebral hematoma is rare and mimics a brain tumor. CASE DESCRIPTION: A 50-year-old man had developed intracerebral hematoma in the right temporal lobe. Computed tomography (CT) showed the gradually decreasing density of the hematoma. However, the hematoma did not decrease in size and it showed ring enhancement on contrast-enhanced CT for more than 1 year. Magnetic resonance imaging (MRI) revealed a lesion content showing a high intensity on both T1- and T2-weighted images with ring enhancement. The lesion was diagnosed as a chronic encapsulated intracerebral hematoma developing from an acute hematoma. Arterial spin labeling of MRI showed decreased blood perfusion even in the enhanced capsule, being different from findings of a cystic brain tumor. CONCLUSION: Arterial spin labeling might be a useful modality to distinguish a chronic encapsulated intracerebral hematoma from a cystic hypervascular brain tumor.

Perforation of superior thyroid artery by guidewire during carotid artery stenting.

BACKGROUND AND AIM: Although carotid artery stenting (CAS) has become a common treatment for carotid artery stenosis, some complications occur related to the procedures. Perforation of an external carotid artery (ECA) branch is a rare complication. CASE DESCRIPTION: An 83-year-old man presented with gait disturbance and dysarthria. MRI demonstrated a fresh cerebral infarction in the watershed territory of the left cerebrum and severe stenosis of the left internal carotid artery (ICA). He underwent CAS for the left ICA stenosis. After the procedure, the patient complained of discomfort of the throat. Swelling of the neck was observed and angiography showed extravasation of contrast medium from the superior thyroid artery. The patient was immediately sedated and intubated. Strict control of the blood pressure was continued. Two days after CAS, the tracheal tube was extracted. He was discharged without deficit on the 17th post-stenting day. CONCLUSION: Injury of ECA branches is a potential complication when a guidewire is inserted during advancement of the materials. It may be life threatening due to associated respiratory problems. Once bleeding from the ECA is suspected, close observation of the patient's neck and respiration and immediate intervention are necessary.

Aneurysm at origin of duplicated middle cerebral artery associated with another aneurysm.

BACKGROUND: A duplicated middle cerebral artery (DMCA) is a rare vessel anomaly. Aneurysms at the origin of DMCA have been reported. CASE DESCRIPTION: We report 2 cases of aneurysms at the origin of DMCA accompanied by aneurysms at different sites. Each case of ruptured and unruptured aneurysm at the DMCA origin was associated with an unruptured aneurysm at the ipsilateral internal carotid artery and a ruptured one at the ipsilateral MCA, respectively. The aneurysms were clipped successfully in both patients. CONCLUSION: In cases of DMCA aneurysm associated with an aneurysm at another site, either aneurysm has a high risk of rupture. In such a case, radical treatment is necessary.

Accessory middle cerebral artery associated with an unruptured aneurysm at its origin.

BACKGROUND: An aneurysm originating from the junction of the A1 segment of the anterior cerebral artery and accessory middle cerebral artery (Acc-MCA) is markedly rare. We report a rare case of an Acc-MCA aneurysm, and discuss the clinical course and management of this rare condition. CASE DESCRIPTION: A 64-year-old man with a past history of cerebral infarction was revealed to have a left Acc-MCA and an aneurysm at its origin. The aneurysm was clipped via a transsylvian approach. Due to its location and projectile direction, the neck of the aneurysm was left partially unclipped. CONCLUSION: Although an Acc-MCA aneurysm is very rare, it has a potential risk of rupture. Therefore, radical treatment is necessary for such aneurysms.

Sugar-sensitive thin films composed of concanavalin A and glycogen.

Sugar-sensitive thin films were prepared by a layer-by-layer deposition of concanavalin A (Con A) and glycogen on the surface of a quartz slide and their sugar-induced decomposition was studied. The Con A/glycogen multilayer films can be decomposed by exposing them to sugar solutions (D-glucose, D-mannose, methyl-alpha-D-glucose and methyl-alpha-D-mannose), as a result of displacement of sugar residues of glycogen from the binding sites of Con A by the free sugar added in the solution. The rate of decomposition significantly depended on the type of sugar and its concentration.

Cerebellar hemorrhage after embolization of ruptured vertebral dissecting aneurysm proximal to PICA including parent artery.

BACKGROUND: Some complications related to vertebral artery occlusion by endovascular technique have been reported. However, cerebellar hemorrhage after vertebral artery occlusion in subacute phase is rare. In this report, we describe a patient who showed cerebellar hemorrhage during hypertensive therapy for vasospasm after embolization of a vertebral dissecting aneurysm. CASE DESCRIPTION: A 56-year-old female with a ruptured vertebral dissecting aneurysm proximal to the posterior inferior cerebellar artery developed cerebellar hemorrhage 15 days after embolization of the vertebral artery, including the dissected site. In this patient, the preserved posterior inferior cerebellar artery fed by retrograde blood flow might have been hemodynamically stressed during hypertensive and antiplatelet therapies for subarachnoid hemorrhage, resulting in cerebellar hemorrhage. CONCLUSION: Although cerebellar hemorrhage is not prone to occur in the nonacute stage of embolization of the vertebral artery, it should be taken into consideration that cerebellar hemorrhage may occur during hypertensive treatment.

High-resolution magnetic resonance imaging findings of basilar artery plaque in a patient with branch atheromatous disease: a case report.

INTRODUCTION: Intracranial branch atheromatous disease is a type of ischemic stroke that is caused by narrowing or occlusion of the orifice of the penetrating artery by atheromatous plaque. Pontine branch atheromatous disease is usually diagnosed using indirect findings such as the extension of a lesion to the basal surface of the pons because of the difficulty of demonstrating plaque in the basilar artery. CASE PRESENTATION: A 72-year-old Japanese man developed sudden dysarthria and left hemiparesis, and his symptoms deteriorated thereafter. Brain magnetic resonance imaging revealed an acute infarction in the territory of the right paramedian pontine artery extending to the basal surface. Non-contrast-enhanced three-dimensional fast spin-echo T1 imaging with variable flip angles and three-dimensional fast imaging with steady-state acquisition revealed a plaque in the dorsal wall of the basilar artery that spread to the origin of the paramedian pontine artery that branched toward the infarction. Although antithrombotic agents were started, the left hemiparesis got worse and became flaccid on the following day. CONCLUSIONS: This is the first report to confirm the pathological basis of branch atheromatous disease by three-dimensional images using the new modalities of 3-Tesla magnetic resonance imaging. The use of these techniques will foster better understanding of the clinicopathological mechanisms of branch atheromatous disease.

A chronic intracerebral fluid hematoma.

Intracerebral hematoma usually resolves and a chronic fluid hematoma is rare. We describe a rare case of intracerebral fluid hematoma. This report describes a case of intracerebral fluid hematoma mimicking a brain tumor and discusses the characteristics of this condition. A 70-year-old woman had a six-month history of memory disturbance. Computed tomography scan showed a low-density lesion with a partial high-density area in the right frontal lobe. MRI revealed a lesion of the main cystic portion showing high intensity on both T1 and T2 weighted images with a low-intensity solid portion in the anteromedial side. The lesion was adjacent to the lateral ventricle. Craniotomy was carried out and the lesion was removed. Pathological examination of the solid portion revealed that the diagnosis was reactive changes due to intracerebral hemorrhage. In our case, there was a possibility that the hematoma was diluted with cerebrospinal fluid, and coagulation might have been prevented.

Arterial spin-labeling magnetic resonance imaging for diagnosis of late seizure after stroke.

BACKGROUND AND PURPOSE: Arterial spin labeling (ASL) is a non-invasive modality of magnetic resonance imaging (MRI) used to evaluate cerebral perfusion without a contrast agent. The usefulness of ASL for diagnosis in the acute phase of late seizure after stroke was evaluated. METHODS: Twelve consecutive patients diagnosed with late seizure after stroke were enrolled in this study. MRI including ASL was performed for each patient at the time of the emergency department visit. Eight of the patients underwent electroencephalography (EEG). RESULTS: All patients showed hyperperfusion around the stroke lesion on ASL. Only 6 patients showed high signal intensity along the cerebral cortex around the stroke lesion on diffusion-weighted imaging. The patients who underwent EEG showed slow activity, but paroxysmal discharges such as spikes or sharp waves were not observed. CONCLUSIONS: ASL was able to reveal hyperperfusion and was of great diagnostic value in the peri-ictal phase of late seizure after stroke.