Endovascular Treatment for Spontaneous bilateral carotid artery dissection with acute ischemic stroke: A Case Report with automated postprocessing CT perfusion findings and Review of the Literature.

Carotid artery dissection (CAD) is a common cause of stroke, accounting for up to 25% of all ischemic strokes in young and middle-aged patients. CAD should be considered in young patients with unexplained head and neck pain, with or without focal neurological symptoms and signs. While the clinical features may raise suspicion for CAD, the diagnosis is confirmed by its typical neuroimaging findings. Meanwhile, simultaneous spontaneous dissection of the bilateral carotid artery has rarely been reported. We herein describe a clinically challenging case of a simultaneous bilateral CAD that was successfully treated with bilateral carotid artery stenting (CAS). The patient recovered satisfactorily after completing the whole course of treatment. Keywords: Acute stroke, Bilateral Spontaneous carotid artery dissection, Endovascular treatment.

Stroke Risk in Young Women with Primary Dysmenorrhea: A Propensity-Score-Matched Retrospective Cohort Study.

BACKGROUND: Studies on strokes associated with dysmenorrhea are limited. We conducted a propensity-score-matched retrospective cohort study to assess the risk of stroke in women with primary dysmenorrhea (PD). METHODS: From the claims data of one million people in Taiwan's insurance program, we identified 18,783 women aged 15-40 years, newly diagnosed with PD in 2000-2010, without a history of stroke. We randomly selected a comparison cohort without stroke history and dysmenorrhea, with the same sample size matched by age, index date, and propensity score. We began a follow-up with individuals one year after cohort entry to the end of 2013 to capture stroke events. RESULTS: The two study cohorts were well-matched for age and comorbidities, with 54% of women aged 15-24. Stroke incidence was 1.5-fold higher in the PD cohort than in the comparison cohort (6.05 vs. 4.01 per 10,000 person-years, or 99 vs. 65 cases), with an adjusted hazard ratio (aHR) of 1.51 (95%CI 1.11-2.06) after adjustment for matched pairs. Nearly 70% of strokes were ischemic strokes, which occurred 1.6 times more frequently in the PD cohort than in the comparison cohort (4.40 vs. 2.71 per 10,000 person-years, or 72 vs. 44 cases), aHR = 1.61 (95% CI 1.11-2.33), after adjustment for matched pairs. The incidence of hemorrhagic stroke was also higher in the PD cohort than in the comparison cohort (1.65 vs. 1.29 per 10,000 person-years, or 27 versus 21 cases), but the difference was not significant. CONCLUSION: Women of reproductive age with PD are at increased risk for ischemic stroke.

Risk of Ischemic Heart Disease Associated with Primary Dysmenorrhea: A Population-Based Retrospective Cohort Study.

The awareness on ischemic heart disease (IHD) in women with dysmenorrhea is insufficient. We utilized the National Health Insurance Research Database (NHIRD) of Taiwan to evaluate this relationship. From the claims data, we established a cohort of women aged 15-50 years with primary dysmenorrhea diagnosed from 2000 to 2008 (n = 18,455) and a comparison cohort (n = 36,910) without dysmenorrhea, frequency matched by age and diagnosis date. Both cohorts were followed until the end of 2013 to assess IHD events. With 75% of study population aged 15-29 years, the incidence of IHD was greater in the dysmenorrheal cohort than in the comparison cohort (1.93 versus 1.18 per 10,000 person-years), with an adjusted hazard ratio of 1.60 (95% confidence interval [CI] = 1.38-1.85). The incidence increased with age and the rate of increase was greater in the dysmenorrheal cohort than the comparison cohort. Nested case-control analysis in the dysmenorrhea cohort showed that IHD risk was also associated with hypertension and arrhythmia, with adjusted odds ratios of 2.50 (95% CI = 1.64-3.81) and 3.30 (95% CI = 2.25-4.86), respectively. Women with dysmenorrhea are at a higher risk of developing IHD, particularly for older patients and patients with comorbidity.

Predictors of unfavorable outcome at 90 days in basilar artery occlusion patients.

BACKGROUND: In a previous study, basilar artery occlusion (BAO) was shown to lead to death or disability in 80% of the patients. The treatment for BAO patients in the acute stage includes thrombolysis and intra-arterial thrombectomy, but not all patients benefit from these treatments. Thus, understanding the predictors of outcome before initiating these treatments is of special interest. AIM: To determine the predictors related to the 90-d clinical outcome in patients with BAO in an Asian population. METHODS: We performed a retrospective case review of patients admitted to a tertiary stroke center between 2015 and 2019. We used the international classification of diseases-10 criteria to identify cases of posterior circulation stroke. A neurologist reviewed every case, and patients fulfilling the criteria defined in the Basilar Artery International Cooperation Study were included. We then analyzed the patients' characteristics and factors related to the 90-d outcome. RESULTS: We identified a total of 99 patients as real BAO cases. Of these patients, 33 (33.3%) had a favorable outcome at 90 d (modified Rankin Scale: 0-3). Moreover, 72 patients received intra-arterial thrombectomy, while 13 patients received intravenous tissue-type plasminogen activator treatment. We observed a favorable outcome in 33.3% of the cases and an unfavorable outcome in 66.7% of the cases. We found that the initial National Institutes of Health Stroke Scale (NIHSS) score and several BAO symptoms, including impaired consciousness, tetraparesis, and pupillary abnormalities, were significantly associated with an unfavorable outcome (P < 0.05), while cerebellar symptoms were associated with a favorable outcome (P < 0.05). In the receiver operating characteristic (ROC) analysis, the areas under the ROC curve of initial NIHSS score, impaired consciousness, tetraparesis, cerebellar symptoms, and pupillary abnormalities were 0.836, 0.644, 0.727, 0.614, and 0.614, respectively. Initial NIHSS score showed a higher AUROC (0.836) compared to BAO symptoms. CONCLUSION: The most important predictor of an unfavorable outcome was the initial NIHSS score. BAO symptoms, including tetraparesis, impaired consciousness, and pupillary abnormality were also related to an unfavorable outcome.

Propofol Causes Sustained Ca2+ Elevation in Endothelial Cells by Stimulating Ryanodine Receptor and Suppressing Plasmalemmal Ca2+ Pump.

ABSTRACT: Propofol, a general anesthetic administered intravenously, may cause pain at the injection site. The pain is in part due to irritation of vascular endothelial cells. We here investigated the effects of propofol on Ca2+ transport and pain mediator release in human umbilical vein endothelial cells (EA.hy926). Propofol mobilized Ca2+ from cyclopiazonic acid (CPA)-dischargeable pool but did not cause Ca2+ release from the lysosomal Ca2+ stores. Propofol-elicited Ca2+ release was suppressed by 100 µM ryanodine, suggesting the participation of ryanodine receptor channels. Propofol did not affect ATP-triggered Ca2+ release but abolished the Ca2+ influx triggered by ATP; in addition, propofol also suppressed store-operated Ca2+ entry elicited by CPA. Ca2+ clearance during CPA-induced Ca2+ discharge was unaffected by a low Na+ (50 mM) extracellular solution, but strongly suppressed by 5 mM La3+ (an inhibitor of plasmalemmal Ca2+ pump), suggesting Ca2+ extrusion was predominantly through the plasmalemmal Ca2+ pump. Propofol mimicked the effect of La3+ in suppressing Ca2+ clearance. Propofol also stimulated release of pain mediators, namely, reactive oxygen species and bradykinin. Our data suggest propofol elicited Ca2+ release and repressed Ca2+ clearance, causing a sustained cytosolic [Ca2+]i elevation. The latter may cause reactive oxygen species and bradykinin release, resulting in pain.

Use of a Smartphone Application to Speed Up Interhospital Transfer of Acute Ischemic Stroke Patients for Thrombectomy.

Background: In most countries, large cerebral artery occlusion is identified as the leading cause of disability. In 2015, five large-scale clinical trials confirmed the benefit of intra-arterial thrombectomy. However, thrombectomy is a highly technical and facility-dependent procedure. Primary stroke centers need to transfer patients to comprehensive stroke centers to perform thrombectomy. The time-lapse during interhospital transfer would decrease the chance of the patient's proper recovery. Communication barriers also contribute to this delay. Aims: We used a smartphone application to overcome communication barriers between hospitals. We aimed to shorten the door-to-puncture time of interhospital transfer patients. Methods: We began using a smartphone application, "LINE," to facilitate interhospital communication on May 01, 2018. We carried out retrospective data analyses for all the transfer patients (n = 351), with the primary outcome being the door-to-puncture time in our comprehensive stroke center (China Medical University Hospital). We compared the three periods: May 01 to Dec 31, 2017 (before the use of the smartphone application); May 01 to Dec 31, 2018 (the 1st year of using the smartphone application); and May 01 to Dec 31, 2019 (the 2nd year of using the smartphone application). We also compared the transfer data with non-transfer thrombectomies in the same period. Results: We compared 2017, 2018, and 2019 data. The total number of transfer patients increased over the years: 63, 113, 175, respectively. The mean door-to-puncture time decreased significantly, going from 109, through 102, to 92 min. Meanwhile, the mean door-to-puncture time in non-transfer patients were 140.3, 122.1, and 129.3 min. The main reason of time saving was the change of the way of communication, from point-to-point interhospital communication to hub-to-spoke interhospital communication. Conclusions: We used this smartphone application to enhance interhospital communication, changed from the point-to-point to hub-to-spoke method. It made us overcome the communication barrier and build up interhospital connection, thus shortening the door-to-puncture time. Our experience demonstrated the importance of close communication and teamwork in hyperacute stroke care, especially in interhospital transfer for thrombectomy.

Sonographic Clue in Non-traumatic Carotid-cavernous Fistula: Report of a Case and Literature Review.

BACKGROUND: Failure to recognize a carotid-cavernous fistula (CCF) promptly may lead to worse prognosis due to a setback in providing proper treatment. To promote early diagnosis of non-traumatic CCF, we report a case with classic clinical symptoms and signs that was diagnosed and followed up with carotid Doppler sonography (CDS) and transcranial color-coded duplex (TCD). CASE REPORT: A 45-year-old woman developed an intermittent headache, pulsatile tinnitus, and double vision sequentially within ten days. Progressive left retro-orbital pain, continuous ringing in the left ear, sensory impairment of trigeminal nerve and abducens nerve palsy were also noted on examination. Despite insignificant findings on computed tomography (CT) of the brain, TCD revealed an aberrant flow pattern with high velocity and low resistance at the left carotid siphon. Digital subtraction angiography (DSA) later confirmed a left direct type CCF by illustrating a quick opacification of left cavernous sinus via the internal carotid artery. CONCLUSION: In addition to invasive DSA, non-invasive CDS and TCD may serve as useful apparatus during the initial evaluation and subsequent follow-ups. The positive sonographic clues, including abnormal turbulent and hemodynamic parameters, are quite exhibitive in the existence of CCFs.

Brain Metabolism of Less-Educated Patients With Alzheimer Dementia Studied by Positron Emission Tomography.

Alzheimer dementia (AD) is the commonest form of dementia. Although illiteracy is associated with high prevalence of dementia of the Alzheimer type (DAT), their relationship is still unclear. Nevertheless, mild DAT in illiterate participants seems to be due to brain atrophy.In this study, we compared the impact of brain metabolism efficiency in healthy participants and less-educated patients with mild DAT using 2-fluoro-2-deoxy-D-glucose (F-FDG-PET) positron emission tomography. Out of 43 eligible less-educated participants with dementia, only 23 (14 women and 9 men) met Diagnostic and Statistical Manual (DSM)-III-R or DSM-IV criteria for DAT and AD and were included. Participants with intracranial insults were excluded by brain magnetic resonance imaging and participants with metabolic or systemic conditions were excluded by blood sampling. In addition, 16 cognitively normal elderly (age >70 years), including 7 women and 9 men, were enrolled in the sham group. The PET imaging data were analyzed using statistical parametric mapping (SPM8) to determine reliability and specificity.Glucose metabolic rate was low in the DAT group, especially in the middle temporal gyrus, middle frontal gyrus, superior frontal gyrus, inferior frontal gyrus, posterior cingulate gyrus, angular gyrus, parahippocampal gyrus, middle occipital gyrus, rectal gyrus, and lingual gyrus.Our results showed that DAT patients with less education not only have prominent clinical signs and symptoms related to dementia but also decreased gray matter metabolism.

Embolization followed by surgery for treatment of perimedullary arteriovenous fistula causing acute myelopathy.

BACKGROUND: Perimedullary arteriovenous fistula (AVF) is rare. There are three subtypes, and the treatment strategies for each are different. Subtype B (multiple fistulas) can be treated by either embolization or surgery. On the basis of a case from our treatment experience, we propose a method for achieving optimal outcome while minimizing nerve injury. CASE DESCRIPTION: A 51-year-old female was admitted to our hospital with acute myelopathy caused by a perimedullary AVF. Initially, we treated her by embolization using the chemical agent Onyx. Her symptoms improved immediately but gradually returned beginning 1 week later. Two months later, the symptoms had returned to pretreatment status, so we removed the fistulas surgically. Severe adhesions between nerve and occult venous varices were noted during the operation. Afterward, the patient's symptoms improved significantly. Histopathological sections showed an inflammatory reaction around the varices. CONCLUSIONS: We initially considered several possible reasons for the return of symptoms: (a) Hypoperfusion of the spinal cord; (b) mass effect of the occult vein varices; (c) residual AVF or vascular remodeling resulting in recurrent cord hypertension; (d) Onyx-induced perivascular inflammation resulting in nerves adhering to each other and to occult venous varices. Clinical, surgical, and pathological findings ruled out the first three, leaving Onyx-induced perivascular inflammation as the probable reason. Given our treatment experience and the pros and cons of the two methods, we propose that initial embolization followed by surgery after 5 days to remove occult venous varices is the ideal strategy for treating perimedullary AVF of subtype B.

Isolated intraventricular aspergillosis in a schizophrenic patient.

Intracranial aspergillosis of the lateral ventricle is a rare condition and has not been reported in a schizophrenic patient. We report a 39-year-old male patient with underlying schizophrenia and a rapid deterioration of consciousness. Initial cranial computed tomographic images revealed focal dilatation of the posterior part of the right lateral ventricle with a severe mass effect and midline shift. The patient received an emergency endoscopic ventriculostomy, and the resected mass was proven to be aspergillus. The patient was postoperatively treated by prolonged external ventricular drainage and antifungal medication, with no recurrence of aspergillosis at the 12-month follow-up.

White Matter tract involvement in brain tumors: a diffusion tensor imaging analysis.

BACKGROUND: Characterization of WM alteration using MR imaging is important in the pre- and intraoperative assessment of brain tumors. This study characterizes the extent and severity of WM tract alterations near brain tumors using DTI in an effort to determine preoperative viability or resectability of the adjacent WM tracts. Fractional anisotropy is an important DTI-derived metric of MR imaging. METHODS: Twenty-one patients underwent MR DTI. Eighty-six WM tracts composed of 43 WM lesions paired with 43 contralateral WM hemispheric controls were categorized using FA. Neuroradiologists categorized the WM tracts as edematous, displaced, disrupted, or infiltrated with tumor using directionally encoded color maps. A mixed model analysis was used to compare FA. RESULTS: Of the lesioned tracts, 5 were scored as edema, 9 as infiltration, 18 as displacement, and 11 as disruption. A significant DeltaFA(%) was found between the lesioned and contralateral hemispheres only in WM disruption (P = .0056). Both edema FA and disruption FA are significantly less than displacement FA (P < .05). The FA change (DeltaFA(%) = [FA(lesion) - FA(normal)]/FA(normal) x 100%) on the lesioned side was calculated. A DeltaFA% less than -30% is likely to be associated with WM disruption. A positive DeltaFA% is likely to be associated with edema or displacement, and a DeltaFA% between 0% and -30% is likely to be associated with WM displacement or infiltration. CONCLUSIONS: Quantitative analysis of DTI data may provide insight as to whether WM tracts are salvageable preoperatively.

Heroin vapor inhalation-induced spongiform leukoencephalopathy.

A 26-year-old man with a 3-year history of heroin vapor inhalation developed spongiform leukoencephalopathy. T2-weighted magnetic resonance imaging showed characteristic high signals over subcortical white matter, including bilateral frontoparietal lobes, posterior limbs of internal capsules, splenium, occipital lobes, cerebellum and brainstem. Signal intensity of diffusion-weighted imaging was high, and apparent diffusion coefficient in corresponding areas was increased. Pathologic features of heroin induced spongiform leukoencephalopathy were unique, characterized by demyelination and vacuolar formation. 99m-Technetium-ECD SPECT and F18 FDG PET demonstrated decreased radiotracer uptake in the corresponding areas. 99m-Technetium-TRODAT SPECT showed no definite decreased uptake of radiotracer at basal ganglia, which suggests that the dopamine neurons were not affected.

Superficial temporal artery-middle cerebral artery bypass for ischemic atherosclerotic middle cerebral artery disease.

Most recent studies on the effectiveness of cerebral revascularization have focused on the treatment of atherosclerotic internal carotid artery occlusive disease. The goal of the present study was to assess neurological function in 11 severe atherosclerotic middle cerebral artery (MCA) disease patients with transient ischemic attacks (TIAs) and hemodynamic compromise and determine the efficacy of superficial temporal artery-middle cerebral artery (STA-MCA) bypass. There were eight patients with MCA occlusion and three with severe MCA stenosis. After the bypass procedure, all 11 patients experienced reduction in TIAs and no stroke during a mean follow-up of 34.36 months. Surgical revascularization increased regional cerebral blood flow (mL/100g/min) from a mean of (+/- standard deviation) 25.9+/-7.39 preoperatively to 32.3+/-7.72 postoperatively, and improved regional cerebrovascular reactivity from -6.42%+/-14.61% to 30.14%+/-23.93% (p = 0.014) in the eight patients with atherosclerotic MCA occlusion. Our findings demonstrated the benefit of STA-MCA bypass for patients with medically refractory and symptomatic atherosclerotic MCA occlusion with hemodynamic compromise.

Endovascular repair of tracheo-innominate artery fistula.

Innominate arterial wall rupture with pseudoaneurysm formation was found during angiography in a 39-year-old woman 2 days after she had undergone percutaneous dilatational tracheostomy. Endovascular stent surgery and balloon angioplasty were performed but these procedures failed to control the massive bleeding resulting from an endoleak. We report the clinical presentations and describe the treatment of a tracheo-innominate artery fistula in our patient. We also reviewed the algorithms of management and the rescue options for treating a tracheo-innominate artery fistula.

Efficacy of anterior cervical fusion: comparison of titanium cages, polyetheretherketone (PEEK) cages and autogenous bone grafts.

This retrospective study was designed to analyze and compare the efficacy and outcomes of anterior cervical fusion using titanium cages, polyetheretherketone (PEEK) cages and autogenous tricortical bone grafts. Fifty-five patients who underwent segmental anterior discectomy with a follow-up period up to 12 months enrolled in this study. They were divided into three groups: titanium cage with biphasic calcium phosphate ceramic (Triosite; Zimmer, Berlin, Germany) in group A (n=27); PEEK cage with Triosite in group B (n=9); and autogenous tricortical iliac crest bone graft in group C (n=19). The fusion rates after 6 months were 37.21% in group A , 93.3% in group B, and 84.85% in group C. The fusion rates after 1 year in groups A, B, and C were 46.51%, 100% and 100%, respectively. The PEEK cage is a viable alternative to autogenous tricortical bone grafts in anterior cervical fusion.

Fluid sign in the treated bodies after percutaneous vertebroplasty.

INTRODUCTION: The aims of this study are to describe non-healing in the treated vertebral body after percutaneous vertebroplasty and analyze the influence of vacuum cleft, location, and severity of collapse on the development of nonunion cement. MATERIALS AND METHODS: Of 208 patients (266 treated vertebral bodies) who were treated with percutaneous vertebroplasty from September 2002 to May 2006, 23 patients (41 treated levels) with residual or recurrent pain underwent follow-up magnetic resonance imaging (MRI) study. Retrospective chart review with analysis of preoperative and postoperative MRIs were performed in these 23 patients. RESULTS: In the 41 treated vertebral bodies, 22 of 41 bodies had vacuum cleft found in the preoperative MRI study. Eight of the 22 treated vertebral bodies with preoperative vacuum clefts were found to have fluid between the interface of cement and the residual bone in the collapsed vertebral bodies on follow-up MRI. The adjacent discs of these treated vertebral bodies were upward/downward displaced. The endplate of the adjacent vertebral body exhibited fibrotic change. Treated bodies with vacuum clefts and level A location (T9, T11, T12, and L1) had higher probability of developing nonunion of the cement with statistical significance. The probability of nonunion cement in severe collapsed bodies might be higher than that of union cement in mild collapsed ones, but was not statistically significant. CONCLUSIONS: Fluid sign in the treated body represents unhealed bone-cement interface. The location of the treated vertebral body and existence of vacuum cleft in the treated bodies may be important factors influencing the nonunion of cement.

Repeat percutaneous vertebroplasty at cemented vertebra with fluid sign and recurrent pain.

SUMMARY: Six patients (three females and three males) were referred from their clinicians for evaluation with complaints of recurrent pain. A followup MRI showed fluid at the cemented vertebral bodies. Repeat percutaneous vertebroplasty (PV) was performed in these six patients at the cemented vertebrae. Pain scores, mobility scores, and spine MRIs before the 1st PV, prior to the repeat PV, and 1 and 3 months after the repeat PV were obtained. One month after the repeat PV, the six patients had a mean pain score reduction of 6.2 points and a mean postoperative pain level reduction of 2.8 points. Four of the six patients demonstrated an improvement in mobility with a 1.7 point mean decrease one month after the repeat PV. There was decreased fluid and bone marrow edema in four of the six patients on the follow-up MRIs one and three months after the repeat PV. Repeat PV at cemented vertebrae with fluid signs may offer therapeutic benefits for recurrent pain.

Stromal cell-derived factor-1 alpha promotes neuroprotection, angiogenesis, and mobilization/homing of bone marrow-derived cells in stroke rats.

Stromal cell-derived factor (SDF)-1alpha is involved in the trafficking of hematopoietic stem cells from bone marrow to peripheral blood, and its expression is increased in the penumbra of the ischemic brain. In this study, SDF-1alpha was found to exert neuroprotective effects that rescued primary cortical cultures from H(2)O(2) neurotoxicity, and to modulate neurotrophic factor expression. Rats receiving intracerebral administration of SDF-1alpha showed less cerebral infarction due to up-regulation of antiapoptotic proteins, and they had improved motor performance. SDF-1alpha injection enhanced the targeting of bone marrow (BM)-derived cells to the injured brain, as demonstrated in green fluorescent protein-chimeric mice with cerebral ischemia. In addition, increased vascular density in the ischemic cortex of SDF-1alpha-treated rats enhanced functional local cerebral blood flow. In summary, intracerebral administration of SDF-1alpha resulted in neuroprotection against neurotoxic insult, and it induced increased BM-derived cell targeting to the ischemic brain, thereby reducing the volume of cerebral infarction and improving neural plasticity.