Intraventricular Silicone Oil Migration Resembling Hemorrhagic Complication in a Patient with Ischemic Stroke Receiving Antithrombotic Therapy.

We report herein a case of intraventricular silicone oil migration, a rare complication of intraocular silicone oil tamponade, mimicking a hemorrhage during antithrombotic therapy for ischemic stroke. A 62-year-old male patient with a history of diabetic retinopathy was admitted for right hemiparesis and dysarthria. Brain magnetic resonance imaging on admission showed an acute left-sided ventral medullary infarction, and antithrombotic therapy was started. Head computed tomography done on the next day after admission showed an area of high-density resembling a hematoma in the lateral ventricle. Additional magnetic resonance imaging in the supine and lateral recumbent positions confirmed migration of the lesion within the ventricles by position, indicating intraventricular silicone oil migration. Several facilities in Japan perform magnetic resonance imaging instead of computed tomography as the first step in assessing stroke in the emergency clinical setting. While the silicone oil used in internal tamponade appears high-density on computed tomography, it does not register as an abnormality on diffusion-weighted imaging, thus creating a pitfall to diagnosis based on this modality.

Tokyo Metropolitan Stroke Emergency Medical Services for Interventional Stroke Treatment: The Tama-REgistry of Acute Thrombectomy (TREAT) Study.

OBJECTIVE: It is not clear how patients with large vessel occlusion (LVO) who have undergone mechanical thrombectomy (MT) were transported to hospitals by emergency medical services. Here, we describe the current status of the stroke delivery system in a large city. METHODS: We investigated data from 328 patients (male, n = 199; average age, 74.8 ± 12.9 years) who underwent MT at 12 facilities in the Tama area of Tokyo, between January 2015 and December 2017. The patients were classified according to the destination institution as Stroke A eligible (group A, n = 266 [8.2%]), Tertiary critical care center (group T; n = 35 [10.7%]), and other destinations such as emergency rooms (group O; n = 27 [8.2%]), and then reasons for using Emergency Medical Service (EMS) services and outcomes were compared among the groups. RESULTS: Rates of milder stroke, and middle cerebral artery occlusion were significantly higher in group A than T, whereas that of vertebral-basilar artery occlusion was significantly lower in group A than in groups T and O. The amount of elapsed time from door to picture (DTP) was significantly lower in group A. The time from onset to recanalization, as well as rates of successful recanalization and favorable outcomes (90-day modified Rankin scale 0-2) did not significantly differ regardless of destination. CONCLUSIONS: Most patients with LVO in the Tama area were categorized into group A. DTP was significantly lower in group A.

Widening Time Disparities between Two Paradigms: Tama-REgistry of Acute Endovascular Thrombectomy.

BACKGROUND: The Tama-REgistry of Acute endovascular Thrombectomy (TREAT) is a multicenter registry of endovascular thrombectomy in the Tama area of Tokyo. The objective of this study was to confirm the real-world status of 2 paradigms of transportation. METHODS: This was a retrospective analysis of data from TREAT. Patients were divided into 2 groups and 2 periods: directly admitted to an endovascular thrombectomy-capable center (ECC; group D)/secondary transfer from a non-ECC (group S), and the first period/the second period. Transfer distance, workflow metrics, and clinical outcomes were analyzed. RESULTS: A total of 326 patients, including 264 in group D and 62 in group S, were analyzed. The median distance from the onset-to-ECC was 3.62km for group D and 7.87km for group S (P < .001). The median onset-to-needle (OTN) time was longer for group S (168 minutes) than group D (138 minutes; P = .006). The median onset-to-reperfusion (OTR) time was significantly shorter for group D (247 minutes) than for group S (304 minutes; P = .029). With respect to the 2 periods, there was no significant difference in onset-to-puncture time between the 2 groups in the first period (207 minutes versus 243.5 minutes, respectively, P = .50), while there was one in the second period (164 minutes versus 246.5 minutes, respectively, P = .02). CONCLUSIONS: This region-wide registry study showed longer OTN and OTR times, with no improvement of the time course over time in patients transported via non-ECCs. These results should be used to create a regional medical policy for the management of acute ischemic stroke.

Thrombectomy for Stroke at 6-24 hours without Perfusion CT Software for Patient Selection.

BACKGROUND: Although, thrombectomy for stroke more than 6 hours after onset supported by automated perfusion computed tomography (CT) software (RAPID, iSchemaView) is effective, this software is not available in Japan. This study aimed to elucidate the efficacy of thrombectomy 6-24 hours after onset in our patient cohort using conventional imaging mismatch. METHODS: Of 586 ischemic stroke patients who underwent thrombectomy registered from January 2015 to December 2017, patients with occlusion of the intracranial internal carotid artery or middle cerebral artery, who had last been known to be well 6-24 hours earlier and who had a prestroke modified Rankin scale (mRS) score 0 or 1 were enrolled. Clinical outcomes were the scores of the utility-weighted (UW) mRS, which ranges from 0 (death) to 10 (no symptom or disability), and the rate of functional independence (mRS score of 0-2) at 90 days. RESULTS: This study sample included 31 patients. The median baseline National Institutes of Health Stroke Scale score was 17 (interquartile range [IQR], 13-20), and the median Diffusion-Weighted Imaging-Alberta Stroke Program Early CT Score was 7 (IQR, 5-8). The median interval between the time that the patient was last known well and revascularization was 741 (IQR, 641-818) minutes. The mean UW mRS score at 90 days was 5.3, the rate of functional independence was 32%, and the 90-day mortality rate was 13%. CONCLUSIONS: Thrombectomy 6-24 hours after onset which can be performed with conventional imaging mismatch might be secured for improving functional independence in stroke patients.

Multicenter Prospective Analysis of Stroke Patients Taking Oral Anticoagulants: The PASTA Registry - Study Design and Characteristics.

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.

X-Shaped Cyclobutane-Linked Tetraporphyrins through a Thermal [2+2] Cycloaddition of Etheno-Fused Diporphyrins.

A nickel-mediated tandem double cyclization of ethynylene-linked dibromodiporphyrins afforded highly reactive etheno-fused diporphyrins, which undergo a thermal [2+2] cycloaddition at the fused C-C double bond to afford the cyclobutane moiety in X-shaped cyclobutane-linked tetraporphyrins. During the reaction of a Zn(II) complex precursor, the initial double cyclization product was converted into the diketodiporphyrin, which exhibits red chemiluminescence under ambient conditions.

Onset to Reperfusion Time Was Not Important in Mechanical Thrombectomy for Elderly Patients: A Retrospective Multicenter Study in Tama Area, Tokyo.

BACKGROUND: Mechanical thrombectomy (MT) has become the standard of care for acute ischemic stroke with large vessel occlusion; however, evidence remains insufficient for MT for elderly patients, especially with respect to factors affecting their outcomes. METHODS: This study was a retrospective analysis of a multicenter registry of MT, called Tama Registry of Acute Endovascular Thrombectomy. Patients were divided by their age into 2 groups: Nonelderly (NE; < 80) and elderly (E; ≥80). Factors related to a good outcome (modified Rankin scale score ≤2) were examined in each group. Onset to reperfusion time (OTR) was stratified into 4 categories: category 1, 0 - ≤180 min; category 2, > 180 - ≤360 min; category 3, > 360 min or onset time not identified; and category 4, effective recanalization not achievable. RESULTS: 143 NE patients and 78 E patients were included in this study. The E group had less chance of achieving a good outcome (NE group 51%, E group 35%; p = 0.024). In the NE group, lower OTR category was an independent prognostic factor for good outcome (p = 0.037, OR = 1.09). However, in the E group, OTR category was not a significant predictor on multivariate analysis. Instead, effective recanalization (p = 0.0081, OR 1.40) and lower National Institute of Health Stroke Scale score at presentation (p = 0.0032, OR 1.02) were the independent predictors. CONCLUSIONS: In MT for elderly patients, effective recanalization improved the patients' outcome but OTR affected less. Further studies are warranted to establish the appropriate patient selection and treatment strategies.

Regionwide Retrospective Survey of Acute Mechanical Thrombectomy in Tama, Suburban Tokyo: A Preliminary Report.

BACKGROUND AND PURPOSE: To improve results of acute thrombectomy, the time from stroke onset to efficient recanalization must be minimized. Studies have confirmed the importance of rapid treatment, workflow, and efficient team-based care for acute thrombectomy in large vessel occlusion. This study examined the challenges facing mechanical thrombectomy in the Tama area (population, 4.3 million), a densely populated urban area of Tokyo, Japan, and analyzed retrospective data from the Tama-REgistry of Acute endovascular Thrombectomy. METHODS: This study was a retrospective observational study using data from Tama-REgistry of Acute endovascular Thrombectomy, a multicenter registry of mechanical thrombectomy for acute ischemic stroke in the Tama area of Tokyo. The survey covered 396 patients with large vessel occlusion who underwent acute thrombectomy between January 2015 and March 2017. Participating facilities are 12 of the 13 recanalization therapy-capable stroke centers. RESULTS: We analyzed 326 cases for which modified Rankin Scale score at 90days was available, of which 264 cases were directly admitted, and 62 cases were transferred from other stroke centers. Median time from stroke onset to hospital arrival was 111 minutes, and from arrival to efficient recanalization was 135 minutes. Efficient recanalization was achieved in 257 cases (78.8%), symptomatic hemorrhage developed in 19 cases (5.8%), and modified Rankin Scale 0-2 at 90days was seen in 129 cases (39.6%). The vast majority of patients (n = 299, 94.3%) were transferred within 10km to the enrolling hospital. CONCLUSIONS: These results provide useful information about the emergent transfer system for patients with large vessel occlusion in a densely populated urban area.

Gene Expression Analysis of the Effect of Ischemic Infarction in Whole Blood.

Given the abundance of stroke patients and deaths from stroke worldwide, many studies concerning the aftermath of stroke are being carried out. To reveal the precise effect of ischemic infarction, we conducted a comprehensive gene expression analysis. Alongside a middle cerebral artery occlusion (MCAO) Sprague-Dawley rat model, we used a group undergoing sham surgery for comparison, which was the same as MCAO surgery but without blood vessel occlusion. Subsequently, infarction of the brains of MCAO-treated rats occurred, but did not occur in the sham-treated rats. Using whole blood, we carried out DNA microarray analysis, revealing the gene expression alterations caused by stroke. Downregulation of immune pathways and cluster of differentiation (CD) molecules indicated immunodepression. By conducting miRNA microarray analysis, we extracted seven miRNAs as significantly regulated: miR-107-5p, miR-383-5p, miR-24-1-5p, mir-191b, miR-196b-5p, and miR-3552 were upregulated, and mir-194-1 was downregulated. Among these seven miRNAs, three had one target mRNA each that was extracted as differentially expressed, and the expression levels of all pairs were inversely correlated. This indicates the occurrence of miRNA-mRNA regulatory systems in blood: between miR-107-5p and H2A histone family member Z (H2afz), miR-196b-5p and protein tyrosine phosphatase receptor type C (Ptprc), and miR-3552 and serine/arginine-rich splicing factor 2 (Srsf2). Moreover, six miRNAs had matching human miRNAs with similar sequences, which are potential human stroke biomarkers.

Spontaneous Bilateral Cervical Internal Carotid and Vertebral Artery Dissection in a Japanese Patient without Collagen Vascular Disease with Special Reference to Single-Nucleotide Polymorphisms.

Spontaneous cervical artery dissection (sCAD) is a major cause of ischemic stroke in young adults. Frequently, sCAD involves multiple neck arteries, accounting for 13%-28% of the total sCAD cases. However, little is known about factors related to multiple sCAD. In this case, a 52-year-old man was admitted due to headache without aura. There was a personal history of migraine with aura and a family history of similar symptoms. The patient's younger brother had a left vertebral artery (VA) dissecting aneurysm and underwent endovascular occlusion of his parent artery at the age of 48. Magnetic resonance imaging of our admitted patient showed hyperintensities in the right internal carotid artery (ICA) without acute infarction, and magnetic resonance angiography revealed a narrowing of the right ICA. Angiography was then performed, which showed a trace of dissection of the left ICA and both VAs as well as the right ICA. The patient did not fulfill any major criteria of collagen vascular disease such as Ehlers-Danlos syndrome type IV or Loeys-Dietz syndrome. The data in our patient are quite similar to those reported in patients with single-nucleotide polymorphism (SNP) of PHACTR1. Obtaining the patient's informed consent, we analyzed a common SNP variation in the rs9349379[G] allele (PHACTR1), which has been reported to be associated with a lower risk of sCAD.

Brainstem infarction with wall-eyed bilateral internuclear ophthalmoplegia syndrome and vertical one-and-a-half syndrome.

We describe a rare case in which both wall-eyed bilateral internuclear ophthalmoplegia syndrome and vertical one-and-a-half syndrome were observed in a 68-year-old man with acute ischemic stroke. Concurrent horizontal and vertical gaze palsies are rare because the corresponding gaze centers are anatomically separated. The complicated gaze palsies observed in this patient might have resulted from long, vertical lesions affecting oculomotor pathways for both sides of the brain stem.

Treatment of cryptogenic new-onset refractory status epilepticus (C-NORSE) with tocilizumab: A case report.

A 35-year-old woman with no prior history of epilepsy developed status epilepticus (SE), which was highly resistant to multiple antiseizure medications and sedatives. The etiology of SE was not identified despite extensive investigation, and the patient was diagnosed with cryptogenic new-onset refractory status epilepticus (C-NORSE). Although first-line immunotherapies such as high-dose corticosteroids and plasma exchange were ineffective, the patient manifested a resolution of SE after the administration of tocilizumab, which inhibits interleukin-6. Non-antibody-mediated inflammation has been hypothesized to be a probable pathophysiology of C-NORSE in recent studies, and tocilizumab may be a plausible second-line treatment.

Accuracy of equilibrium magnetization mapping in sliced two-dimensional spoiled gradient-recalled echo pulse sequence with variable flip angle.

PURPOSE: To evaluate the accuracy of an equilibrium magnetization (M0 ) map obtained using a two-dimensional (2D) spoiled gradient-recalled echo (SPGR) pulse sequence with variable flip angle (VFA). MATERIALS AND METHODS: Single-slice 2D SPGR images of 4% agar gel phantoms with different gadolinium-diethylene triamine pentaacetic acid (Gd-DTPA) concentrations (0-1 mM) were obtained with a VFA (2-30°). The 2D SPGR-VFA data were acquired with different repetition times (TRs; 7.8-117.2 ms), Gaussian and sinc RF pulses, and different field strengths (4.7, 7, and 9.4 Tesla). M0 and T1 maps were calculated from the 2D SPGR-VFA data. M0 and T1 values were compared with those calculated from free-relaxed 2D gradient-recalled echo (GRE) images and inversion recovery-prepared 2D SPGR images. The M0 and T1 slice profiles were also investigated. RESULTS: Consistent M0 values were obtained, regardless of the different Gd concentrations, TRs, and pulse sequences. The M0 slice profiles calculated from the sliced SPGR-VFA data quantitatively reproduced those calculated from the free-relaxed sliced GRE. In contrast, the T1 values calculated from the 2D SPGR-VFA data were underestimated at a high Gd concentration, short TR, and Gaussian RF pulse. CONCLUSION: M0 values calculated from 2D SPGR-VFA images are highly quantitative.

Copper Deficiency in Wilson's Disease with a Normal Zinc Value.

Copper deficiency (CD) is a rare complication of long-term treatment of Wilson's disease (WD) and is usually accompanied by high serum zinc levels. A 57-year-old woman with WD presented with limb weakness and sensory disturbance due to myeloneuropathy and macrocytic anemia after 36 years of treatment. Markedly reduced serum free copper values confirmed CD, which was considered to be caused by progressive dysphagia and severe diarrhea rather than zinc overdose because of the normal serum zinc levels. Discontinuing copper-reducing therapy and increasing copper intake improved her symptoms. Physicians should be alert for the risk of CD in WD patients, especially those with dysphagia.

Embolic Stroke Due to a Mural Thrombus in the Ascending Aorta Following Cisplatin-based Chemotherapy.

A 59-year-old woman with small-cell lung carcinoma achieved tumor disappearance after cisplatin-based chemotherapy (CBC) and radiation treatment but subsequently experienced right hemiparesis and aphasia. Brain magnetic resonance imaging revealed a left middle cerebral artery territory acute infarction and left internal carotid artery occlusion. Ultrasonography revealed a mobile thrombus in the left common and internal carotid arteries, and contrast computed tomography revealed a mural thrombus in the ascending aorta. Based on these findings, embolic stroke due to aortic mural thrombus following CBC was diagnosed. Aortic mural thrombus is a rare complication of CBC but carries a risk of embolic stroke.

Delayed Hemiparkinsonism Associated with Kernohan's Notch in a Patient with a Ruptured Arteriovenous Malformation.

A 24-year-old female patient was admitted for a right frontal intracranial hematoma with an uncal herniation due to a ruptured arteriovenous malformation and therefore underwent emergency surgery. Neuroimaging revealed left-sided midbrain notching against the tentorium, indicating Kernohan's notch phenomenon. She denied experiencing any short-term neurological deficits but right-sided delayed hemiparkinsonism developed 18 months later. Dopamine transporter tracer uptake was severely reduced in the left striatum, suggesting nigrostriatal degeneration secondary to Kernohan's notch. Uncal herniations are potentially fatal, but surgery can save the patient's life and improve the functional outcomes. Clinicians should therefore be aware of delayed hemiparkinsonism as a rare complication of Kernohan's notch phenomenon.

Carotid Endarterectomy for Intractable Repetitive Stenosis Following Carotid Artery Stenting.

BACKGROUND: Restenosis after carotid artery stenting has raised concerns regarding the long-term durability of carotid stenting. Recurrent restenosis after multiple endovascular interventions may pose a challenge for clinicians. CASE DESCRIPTION: We encountered 2 cases of intractable restenosis after redo-carotid artery stenting and performed carotid endarterectomy. We removed the embedded stent and plaque simultaneously, used the internal shunting system, and performed patch angioplasty with no further recurrence. CONCLUSION: Carotid endarterectomy could be considered as a first-line treatment for recurrent stenosis that proves refractory to multiple endovascular interventions.

Neuromyelitis Optica Complicated by Ornithine Transcarbamylase Deficiency Treated Safely with Pulse Steroid Therapy.

Steroid administration to patients with urea cycle disorders can cause hyperammonemia. We encountered a 36-year-old woman with neuromyelitis optica (NMO) complicated by ornithine transcarbamylase (OTC) deficiency. By reducing the doses of steroids and adequate infusion management, we were able to administer pulse steroid therapy without any severe complications. This case indicates the safety of steroid treatment in patients with urea cycle disorders.

Abnormal cardiac [(123)I]-meta-iodobenzylguanidine uptake in multiple system atrophy.

[(123)I]-Meta-iodobenzylguanidine (MIBG) myocardial scintigraphy is useful for distinguishing multiple system atrophy (MSA) from Parkinson disease. In this study, longitudinal observation using MIBG myocardial scintigraphy was carried out in patients with MSA to evaluate the association of myocardial MIBG uptake with clinical features. A total of 96 MIBG examinations were performed in 52 patients with MSA. The heart/mediastinum (H/M) ratio of MIBG uptake at 240 minutes after injection was below the lower limit in 16 patients with MSA (31.3%). Overall, the H/M ratio correlated with neither disease duration nor severity. In the follow-up observations, the H/M ratio did not show any specific trends, in contrast with the continuous decrease observed in patients with Parkinson's disease. This data clearly showed that cardiac MIBG uptake cannot necessarily be preserved in patients with MSA and that approximately 30% of patients with MSA showed decreased MIBG uptake without any correlation to disease duration or severity.

Nicergoline increases serum substance P levels in patients with an ischaemic stroke.

BACKGROUND: Aspiration pneumonia is one of the most important complications following ischaemic stroke, and a leading cause of mortality in stroke patients. This is particularly prevalent in patients with involvement of the basal ganglia, which may be due to impaired neurotransmission through lack of production of substance P. METHODS: Consecutive patients in the chronic stage, 1-3 months after cerebral ischaemic infarction, were assessed for basal ganglia involvement by magnetic resonance imaging. The patients were randomised to 4 weeks of treatment with (n = 25) or without (n = 25) nicergoline (15 mg t.i.d.). Serum concentration of substance P was measured by radioimmunoassay. RESULTS: At entry to the study, mean concentration of substance P was significantly (p < 0.001) lower in patients with bilateral basal ganglia lesions than in patients with no or unilateral basal ganglia involvement. Nicergoline administration caused a significant (p = 0.021) increase from baseline in mean substance P concentration. No significant change was seen in the nicergoline-untreated patients (p = 0.626). Among the patients who received nicergoline, 11 patients had bilateral basal ganglia involvement and there was no significant mean change in substance P in these patients, whereas there was a significant increase (p = 0.032) in the 14 nicergoline-treated patients with no or unilateral basal ganglia involvement. CONCLUSIONS: The present study suggests a possible effect of nicergoline to increase substance P level in ischaemic stroke patients with partial damage to basal ganglia, who have a decreased swallowing response and consequent risk of aspiration pneumonia. Further trials of nicergoline treatment in patients at risk for aspiration pneumonia are warranted.