Relationship between Nutritional Scales and Prognosis in Elderly Patients after Acute Ischemic Stroke: Comparison of Controlling Nutritional Status Score and Geriatric Nutritional Risk Index.

BACKGROUND/AIMS: Undernutrition is common in patients after acute ischemic stroke (AIS) and predicts poor clinical outcomes. We assessed the relationship between undernutrition and prognosis after AIS. METHODS: We retrospectively assessed consecutively hospitalized AIS patients aged ≥65 years. A poor prognosis for patients after AIS was defined as a modified Rankin Scale (mRS) score of ≥3 at discharge. Nutritional status was evaluated based on the degree and risk of undernutrition as determined by the Controlling Nutritional Status (UND-CONUT) and Geriatric Nutritional Risk Index (UNR-GNRI) scores. RESULTS: Among 218 patients (male, 62.8%; median age, 77 years), 81 had a poor prognosis. A significant correlation was found between UND-CONUT and UNR-GNRI scores (p < 0.001, r = 0.433). Patients with a poor prognosis showed significant undernutrition based on UND-CONUT (p = 0.003) but not on UNR-GNRI (p = 0.218). Patients with undernutrition based on UND-CONUT showed poor outcomes: higher mRS scores at discharge, higher percentages of mRS scores of ≥2 and ≥3, and more complications associated with pneumonia. No significant differences were seen between cases with and without undernutrition risk based on UNR-GNRI. CONCLUSION: UND-CONUT appeared to be more useful than UNR-GNRI for predicting the prognosis of elderly patients with AIS at discharge.

Clinical Study of Cerebral Ischemia in Moyamoya Disease from the View of Development of the Anterior Choroidal Artery.

OBJECTIVES: The anterior choroidal artery (AchA) is one of the collateral vessels in moyamoya disease (MMD). The incidence of cerebral ischemia in MMD was analyzed through the association between development of the AchA and advancement of MMD stage. MATERIALS AND METHODS: Twelve patients of MMD with cerebral ischemia (infarction; 9 patients, transient ischemic attack; 3 patients) were enrolled. Advancement of MMD was evaluated using Suzuki's stage. The grades in Suzuki's stage were subclassified into a non-progressive stage for grades 1 and 2, and a progressive stage for grades 4 and 5. Dilatation of the AchA was judged as the presence of development of this artery. Development of the AchA was grouped into proximal type and proximal and distal type. RESULTS: Most frequent locations of infarcts were the anterior and parietal lobes in 6 patients each. Development of the AchA was confirmed on the ischemic side in all patients and on the non-ischemic side in 9 patients. Development of the AchA in the progressive stage was limited in the proximal and distal type on both sides. Development of the AchA in the non-progressive stage was the proximal type on the ischemic side. CONCLUSIONS: The cause of cerebral ischemia was possibly associated with inadequate blood supply of the AchA in the non-progressive stage, and the lower blood flow from the internal carotid artery (ICA) in the progressive stage. Disparity between collateral blood flow from the AchA and the blood flow from the ICA was considered to relate to incidence of cerebral ischemia in MMD.

Late-onset MELAS syndrome with mtDNA 14453G→A mutation masquerading as an acute encephalitis: a case report.

BACKGROUND: A unique patient with MELAS syndrome, who initially masqueraded as having acute encephalitis and was eventually diagnosed with MELAS syndrome harboring a mtDNA 14453G → A mutation, is described. CASE PRESENTATION: A 74-year-old Japanese man was admitted to another hospital due to acute onset of cognitive impairment and psychosis. After 7 days he was transferred to our hospital with seizures and deteriorating psychosis. The results of primary ancillary tests that included EEG, CSF findings, and brain MRI supported the diagnosis of an acute encephalitis. HSV-DNA and antibodies against neuronal surface antigens in the CSF were all negative. With the assistance of the lactate peak on the brain lesions in the magnetic resonance spectroscopy image and genetic analysis of the biopsied muscle, he was eventually diagnosed with MELAS syndrome harboring mtDNA 14453G → A mutation in the ND6 gene. CONCLUSIONS: This case provides a caveat that MELAS syndrome can manifest in the symptoms and ancillary tests masquerading as an acute encephalitis caused by infection or autoimmunity. This is the first adult patient seen to harbor the mtDNA14453G → A with a unique onset, which broadens the phenotypic spectrum of MELAS syndrome associated with ND6 gene mutation.

A case of prosopometamorphopsia caused by infarction of the splenium of the corpus callosum and major forceps.

An adult female complained of enlargement of right eyes in other people. Diffusion-weighted imaging detected an abnormal high-intensity area in the region from the splenium of the corpus callosum to the major forceps on the right side. The patient reported that right eyes appeared larger in size, which suggested prosopometamorphopsia. Adichotic listening test identified left-ear deficit. Acombination of prosopometamorphopsia and left-ear deficit was not identified in the reported patients. Prosopometamorphopsia in most of the reported patients included the eye as did that in our patient. This result suggested the importance of information on the eye in recognizing faces.

Clinical Study of Thirteen Patients with Spinal Cord Infarction.

BACKGROUND: A concept of sensory tracts in the spinal cord has been established in relation to a dorsolateral pathway which is located in the posterior part of the lateral column and conveys the deep sense. METHODS: The clinical status at onset, neurological symptoms, and magnetic resonance imaging (MRI) findings in 13 patients of spinal cord infarction were studied. RESULTS: The clinical status was acute in 11 patients and subacute in 2 patients. Palsy of the extremities was noted in 11 patients. Segmental sensory disturbance was shown in all patients. One patient showed disturbance of all senses and paraplegia, which indicated transverse myelopathy. In the other 12 patients, 11 patients showed impairment of pain sense although joint position sense was preserved, excluding 1 patient whose sensory disturbance showed dysesthesia alone. In these 11 patients, soft touch and vibration senses were impaired in 7 patients. Abnormality of spinal cord MRI was detected 7 patients. The lesions were located in the cervical cord in 3 patients, cervical to thoracic cord in 1 patient, and thoracic cord in 3 patients. CONCLUSIONS: In the 11 patients in whom pain sense was impaired and joint position sense was preserved, involvement of the anterior spinal cord artery (ASCA) was the mainstay. Impairment of vibration sense was accompanied in 7 patients in patients of ASCA infarction. It was speculated that impairment of vibration sense can occur in patients with ASCA infarction whose ischemia spread to the dorsolateral pathway in the posterior part of the lateral column.

Clinical Study on 3 Patients with Infarction of the Vermis/Tonsil in the Cerebellum.

BACKGROUND: Infarction of the vermis and the tonsil in the cerebellum presents as truncal and gait ataxia. Acute rotatory vertigo is often present in infarction of the nodulus in the caudal vermis, which is closely associated with the vestibular pathway, but is minor in infarction of the rostral vermis. The rostral vermis receives input from the dorsal spinocerebellar tract (DSCT) which conveys unconsciousness proprioceptive signals from the ipsilateral lower trunk and leg. The present study investigated the characteristics of infarction of the vermis and the tonsil. PATIENTS AND METHODS: Neuroradiological findings of 3 patients whose lesions were located in the vermis or the tonsil were analyzed. RESULTS: All lesions were located in the anterior lobe in the rostral vermis, the nodulus in the caudal vermis, or the tonsil. Truncal and gait ataxia were exhibited by 3 patients. Rotatory vertigo was exhibited by 2 patients whose lesions were located in the nodulus and the tonsil, but absent in a patient with infarction of the anterior lobe. Lateropulsion opposite the lesion was apparent in a patient with infarction of the tonsil. Gaze-evoked nystagmus was observed in 2 patients with infarction of the nodulus and the tonsil. CONCLUSIONS: The tonsil and the nodulus were considered to have a close relationship with the vestibular pathway. Absence of rotatory vertigo indicated impairment of the DSCT. Our data suggested that the cause of truncal and gait ataxia differed between the rostral vermis and the caudal vermis/tonsil.

Clinical Study of 27 Patients with Medial Medullary Infarction.

BACKGROUND: Medial medullary infarction (MMI) is a rare ischemic stroke. Frequency of each neurological finding in MMI was different in each study. METHODS: We retrospectively evaluated the medical records of patients with cerebral infarction who were admitted between March 1998 and October 2015. Patients in our study were diagnosed as having MMI by magnetic resonance image examination. RESULTS: Of 2727 patients with ischemic stroke, 27 patients (20 males and 7 females) had MMI. The MMI was complicated by infarcts located in the pons (n = 6), cerebellum (n = 2), and lateral medulla (n = 1). One patient had bilateral MMI. Large-artery atherosclerosis was the most common etiology. Motor weakness of the extremities was the most common neurological finding. Diminished contralateral superficial sensation was more common than diminished contralateral vibratory sensation, and these 2 types of sensory disturbance were often complicated. The patients with large MMI significantly more often accompanied diminished touch (P = .003), pain (P = .017), and vibratory (P = .019) sensation. Facial weakness was shown more common contralateral to the infarcts than ipsilateral (n = 8 contralateral, n = 1 ipsilateral). Lingual palsy was also more common contralateral to the lesions (n = 3 contralateral, n = 1 ipsilateral). One patient alone fulfilled the classical Dejerine triad. CONCLUSIONS: In MMI, motor weakness of extremities was commonly shown, and complication of diminished sensations indicated the large infarcts. As for facial weakness and lingual palsy, the supranuclear type was more prominent than the infranuclear type.

Clinical Study of Seven Patients with Infarction in Territories of the Anterior Inferior Cerebellar Artery.

BACKGROUND: The prominent features of anterior inferior cerebellar artery (AICA) infarction are vertigo, cerebellar ataxia, and impaired hearing. The present study investigated neurological characteristics associated with AICA infarction. MATERIALS AND METHODS: The locations of infarcts in 7 patients (age, 32-72 years) with AICA infarction were divided into the lower lateral pons, the middle cerebellar peduncle (MCP), and the cerebellum. RESULTS: Ischemic lesions were located in the MCP in 6 patients, spread to the lower lateral pons in 3, and involved the cerebellum in 4 patients. Standing posture and gait were impaired in all patients. Five and 4 patients had impaired hearing and vertigo, respectively. Two patients had only symptoms of labyrinthine disease, and 1 had these symptoms accompanied by impaired hearing. The symptoms in 2 patients with the lesion in the lateral pons were consistent with those in Gasperini syndrome. Two of 3 patients without vertigo had ataxia of the extremities. Stenosis of the vertebral artery or basilar artery in 5 patients indicated that the etiology was branch atheromatous disease. CONCLUSIONS: The most prominent symptom of truncal and gait ataxia and the frequent association between vertigo and impaired hearing were consistent with the characteristics of AICA infarction. Two patients without vertigo had ataxia of the trunk and extremities that might have been due to involvement of the dorsal spinocerebellar tract in the inferior cerebellar peduncle.

Association of Body Water Balance, Nutritional Risk, and Sarcopenia with Outcome in Patients with Acute Ischemic Stroke: A Single-Center Prospective Study.

In the present study, we examined the inter-relationships between body water balance, nutritional risk, sarcopenia, and outcome after acute ischemic stroke (AIS) in patients who were living independently. We defined abnormal body water balance as overhydration, with an extracellular fluid/total body water ratio > 0.390. A geriatric nutritional risk index (GNRI) < 98 was considered low GNRI. Sarcopenia was defined according to the 2019 Asian Working Group for sarcopenia criteria. Poor outcome was defined as a modified Rankin scale (mRS) score ≥ 3 at discharge. Among 111 eligible patients (40 females, median age: 77 years), 43 had a poor prognosis, 31 exhibited overhydration, 25 had low GNRI, and 44 experienced sarcopenia. Patients with poor outcomes had significantly higher National Institutes of Health Stroke Scale (NIHSS) scores, which were significantly more common with overhydration, low GNRI, and sarcopenia (p < 0.001 for all). Concomitant overhydration, low GNRI, and sarcopenia were associated with poorer outcomes. In multivariate analysis, overhydration [odds ratio (OR) 5.504, 95% confidence interval (CI) 1.717-17.648; p = 0.004], age (OR 1.062, 95%CI 1.010-1.117; p = 0.020), and NIHSS score (OR 1.790, 95%CI 1.307-2.451; p < 0.001) were independent prognostic factors for poor outcome. The results indicated that the combination of overhydration, low GNRI, and sarcopenia predict poor outcomes following AIS. Overhydration was particularly associated with poor outcomes.

Post-Stroke Pneumonia in Real-World Practice: Background, Microbiological Examination, and Treatment.

Post-stroke pneumonia (PSP) has an impact on acute ischemic stroke (AIS). Although predictive scores for PSP have been developed, it is occasionally difficult to predict. Clarifying how PSP was treated after its onset in clinical practice is important. Admitted patients with AIS over a 2-year period were retrospectively reviewed. Of 281 patients with AIS, 24 (8.5%) developed PSP. The integer-based pneumonia risk score was higher in patients with PSP. The onset of PSP was frequently seen up to the 4th day of hospitalization. Of patients with PSP, sputum examination yielded Geckler 4 or 5 in only 8.3%. Angiotensin-converting enzyme inhibitor (ACE-I) was more frequently administered to patients with PSP; however, all these cases were started with ACE-I following PSP onset. Nasogastric tubes (NGTs) were inserted in 16 of the patients with PSP, of whom 11 were inserted following PSP onset. Multivariate analysis showed that PSP onset was a poor prognostic factor independent of the female sex, urinary tract infection, and National Institutes of Health Stroke Scale. PSP treatment would benefit from the administration of antimicrobials and ACE-I, as well as NGT insertion. To select effective agents for PSP and evaluate the indications for NGT insertion, further case studies are needed.

Two Patients with Spontaneous Spinal Epidural Hematoma Carrying a Good Prognosis without Surgical Operations.

(1) Introduction: Spontaneous spinal epidural hematoma (SSEH) points to hematoma within the epidural space of the spinal cord without traumatic or iatrogenic causes. (2) Case Reports: One patient showed paraplegia, numbness of both legs with acute onset, acute myelopathic signs, subsequent to back pain. Magnetic resonance imaging (MRI) showed hematoma in the posterior part of the thoracic spinal cord. Another patient showed acute numbness in the shoulder, upper part of the back, and the upper extremity on the right side after pain in the back, shoulder, and neck on the right side. Sagittal computed tomography (CT) images of the cervical bone showed a high-density area behind the spinal cord between C4 and C7. MRI analysis showed hematoma in the right diagonally posterior part of the cervical spinal cord. These 2 patients lacked traumatic or iatrogenic events, and their symptoms abated without surgical operation. (3) Conclusions: The location of hematoma correlated with symptoms in each patient. SSEH is rare but should be taken into account in patients with myelopathy or radiculopathy with acute onset subsequent to back pain. The usefulness of emergent CT scans of the spinal cord prior to MRI analysis was shown in the diagnosis of SSEH.

Cerebellar Progressive Multifocal Leukoencephalopathy Mimicking Anti-Yo-Antibody-Associated Rapidly Progressive Cerebellar Syndrome.

A 58-year-old woman with a history of systemic lupus erythematosus (SLE) who was taking prednisolone and mycophenolate mofetil presented with gait disturbances that progressively worsened over a period of 3 months. Her blood test and cerebrospinal fluid (CSF) examination results did not indicate active SLE. Initial brain magnetic resonance imaging (MRI) revealed a small spotty lesion in the left cerebellar peduncle. The clinical course was consistent with rapidly progressive cerebellar syndrome (RPCS), which sometimes involves neuronal antibodies. The line blot assay detected anti-Yo antibodies, but no malignancy was found. Immunohistological techniques using rat brain sections yielded a negative result for anti-Yo antibodies. The second MRI revealed a focal lesion and surrounding spotty lesion in the left cerebellar peduncle, which was consistent with the punctate pattern observed in progressive multifocal leukoencephalopathy (PML). The CSF JCV-DNA test indicated the presence of cerebellar PML. Immunosuppressants were reduced, and mefloquine and mirtazapine were initiated. After approximately 2 years and 1 month, the CSF JCV-DNA results became negative. Cerebellar PML may exhibit a clinical course that is consistent with RPCS. The punctate pattern should be recognized as an early manifestation of PML. The CSF JCV-DNA copy number may serve as a useful indicator of PML stabilization.

Clinical Features of Acute Ischemic Stroke Patients with Hypoesthesia as an Initial Symptom.

This study aimed to evaluate the clinical characteristics of acute ischemic stroke (AIS) patients who experienced hypoesthesia as the initial symptom. We retrospectively analyzed the medical records of 176 hospitalized AIS patients who met our inclusion and exclusion criteria and evaluated their clinical features and MRI findings. Among this cohort, 20 (11%) patients presented with hypoesthesia as the initial symptom. MRI scans of these 20 patients identified lesions in the thalamus or pontine tegmentum in 14 and brain lesions at other sites in 6. The 20 hypoesthesia patients had higher systolic (p = 0.031) and diastolic blood pressure (p = 0.037) on admission, and a higher rate of small-vessel occlusion (p < 0.001) than patients without hypoesthesia. The patients with hypoesthesia had a significantly shorter average hospital stay (p = 0.007) but did not differ significantly from those without hypoesthesia in National Institutes of Health Stroke Scale scores on admission (p = 0.182) or the modified Rankin Scale scores for neurologic disability on discharge (p = 0.319). In the patients with acute onset hypoesthesia, high blood pressure, and neurological deficits were more likely to be due to AIS than other causes. Since most of the lesions in AIS patients with hypoesthesia as the initial symptom were found to be small, we recommend performing MRI scans with such patients to confirm AIS.

Intramedullary spinal cord abscess associated with right-to-left shunt via right superior vena cava draining into left atrium: A case report.

RATIONALE: Intramedullary spinal cord abscess (ISCA) is a rare but treatable bacterial infection of the central nervous system, and the etiology in no less than 40% of the cases is cryptogenic. Although a few cases of ISCA in individuals with a right-to-left shunt (RL shunt) have been reported, only few arguments focused on the association between RL shunt and ISCA have been provoked. The right superior vena cava (RSVC) draining into the left atrium (LA) is an uncommon systemic venous anomaly that results in an RL shunt, and this anomaly causes several types of neurological complication such as stroke or brain abscess. We report the first case of ISCA associated with RSVC-LA RL shunt. PATIENT CONCERNS: A 36-year-old man developed progressive paraparesis, dysuria, and spontaneous pain in the lumbar region and lower extremities. Spinal magnetic resonance imaging revealed an intramedullary lesion extended from Th12 to L2 with ring-shaped gadolinium enhancement. Cerebrospinal fluid (CSF) study exhibited a marked pleocytosis, and CSF culture grew Streptococcus intermedius. Cardiovascular computed tomography angiography identified RSVC-LA RL shunt, which caused transient acute cardiac syndrome due to air embolus. DIAGNOSES: The patient was diagnosed with ISCA associated with an RSVC-LA RL shunt. INTERVENTIONS: The patient was treated with a combination of intravenous administration of meropenem and vancomycin in a daily dose of 6 and 2.5 g, respectively, followed by intravenous administration of ampicillin in a daily dose of 750 mg. The intravenous antibiotic therapy was continued for 37 days. OUTCOMES: A favorable neurological outcome was obtained by the intravenous antibiotic therapy, and recurrence of infection was prevented by continuous oral antibiotic therapy for 18 months. LESSONS: With a literature review of ISCA associated with RL shunt, we insist that screening for RSVC-LA is beneficial to patients who are diagnosed with cryptogenic ISCA as its identification leads to appropriate preventive therapy.

Delayed encephalopathy after COVID-19: A case series of six patients.

RATIONALE: Acute encephalopathy is a severe neurological complication of coronavirus disease 2019 (COVID-19). Most cases of acute encephalopathy associated with COVID-19 occur within several weeks of COVID-19 onset. We describe a case series of 6 patients who developed delayed encephalopathy (DE) after COVID-19. PATIENT CONCERNS AND DIAGNOSES: We evaluated patients who recovered from COVID-19 and showed acute disturbance of consciousness or focal neurological deficits without recurrence of pneumonitis. Six patients, 2 females and 4 males, with ages ranging from 65 to 83 years were included. Durations of hospitalization due to COVID-19 were between 25 and 44 days. The severity of COVID-19 was moderate in 5 and severe in 1 patient. Patients were rehospitalized for acute disturbance of consciousness concomitant with postural tremor and, abnormal behavior, hemiplegia, aphasia, or apraxia between 34 and 67 days after the onset of COVID-19. Chest computed tomography showed no exacerbation of pneumonitis. Brain magnetic resonance imaging showed no specific findings except in 1 patient with an acute lacunar infarction. Electroencephalogram demonstrated diffuse slowing in all patients. Repeat electroencephalogram after recovery from encephalopathy demonstrated normal in all patients. One of the 6 patients had cerebrospinal fluid (CSF) pleocytosis. CSF protein levels were elevated in all patients, ranging from 51 to 115 mg/dL. CSF interleukin-6 levels ranged from 2.9 to 10.9 pg/mL. The immunoglobulin index was 0.39 to 0.44. Qlim(alb) < QAlb indicating dysfunction of the blood-brain barrier was observed in all patients. Severe acute respiratory syndrome coronavirus 2 reverse transcription polymerase chain reaction of CSF was negative in all patients. Neuronal autoantibodies were absent in serum and CSF. INTERVENTIONS AND OUTCOMES: Immunotherapy including steroid pulses was administered to 3 patients; however, symptoms of encephalopathy resolved within several days in all patients, regardless of treatment with immunotherapy, and their consciousness levels were recovered fully. Notably, postural tremor remained for 2 weeks to 7 months. LESSONS: In our patients, DE after COVID-19 was characterized by symptoms of acute encephalopathy accompanied with tremor in the absence of worsening pneumonitis after the fourth week of COVID-19 onset. Our findings indicate blood-brain barrier dysfunction may contribute to the pathogenesis of DE after COVID-19.

Ruptured long intramedullary spinal cord abscess successfully treated with antibiotic treatment.

Intramedullary spinal cord abscess (ISCA) is an extremely rare infection of the central nervous system. We report a 17-year old man with ISCA that suggested rupture confirmed by magnetic resonance imaging (MRI). The patient presented with meningeal signs, severe paraplegia, sensory impairment with a sensory level, and urinary retention. The cerebrospinal fluid (CSF) study showed pleocytosis with polymorphonuclear cells and a decreased glucose level suggesting bacterial meningitis. Computed tomography showed maxillary sinusitis and a lower respiratory tract infection. Spinal MRI showed an ISCA from Th5 to Th12. Part of the abscess seemed to have ruptured into the medullary cavity. Streptococcus intermedius was cultured from CSF, sputum, and the maxillary sinus abscess. It appeared that Streptococcus intermedius transferred from the respiratory tract to the spinal cord hematogenously, formed the ISCA, and the ISCA ruptured. The patient was treated with ampicillin, vancomycin, and meropenem. After 56 days of treatment, he could walk with a walker. In the present case, the MRI findings were helpful for early diagnosis and follow-up of the pathogenic condition. Although the present case suggested rupture of ISCA, he recovered with antibiotic therapy alone. This suggested earlier diagnosis with MRI and aggressive antibiotic therapy appear to be critical factors that determine the prognosis of patients with ISCA.

Relationship between Cytotoxicity in the Hippocampus and an Abnormal High Intensity Area on the Diffusion-weighted Images of Three Patients with Transient Global Amnesia.

Objective An abnormal high intensity area (HIA) on diffusion-weighted imaging (DWI) indicates the presence of cytotoxic edema and has been reported to be observed in the hippocampus of patients with transient global amnesia (TGA). The appearance of an HIA on DWI is usually delayed after the onset of patients with amnesia in TGA; thus, the significance of the HIA was evaluated in patients with TGA. Methods Three adult TGA patients who had a unilateral HIA on DWI (right, n=2; left, n=1) were enrolled. These patients were hospitalized due to acute-onset amnesia. Amnesia subsided within 24 hours of hospitalization in all three patients. Results The HIA was confined to the upper lateral zone of the body in the unilateral hippocampus where the CA1 region exists. The lesions were confirmed after the improvement of amnesia in the three patients. The location of the lesions corresponded to the watershed area where the upper and lower hippocampal arteries were anastomosed. Conclusion Cytotoxicity caused by glutamate-mediated calcium influx in the neurons of the CA1 region was recently reported in the pathogenesis of TGA. Based on the pathogenesis, the cytotoxicity was considered to have been caused by calcium overload throughout the entire CA1 region, and amnesia occurred due to this cytotoxicity. The cytotoxicity was more marked in the lesions because of the lower blood flow in the watershed area and was prolonged after the function of the CA1 region (excluding the watershed area) improved, which led to cytotoxic edema in the lesions.

Small, smooth, nonmobile cardiac myxoma detected by transesophageal echocardiography following recurrent cerebral infarction: a case report.

BACKGROUND: Cardiac myxoma is known to cause repeated events of cerebral embolism. Soft and irregularly shaped myxomas with high mobility are associated with a higher occurrence of cerebral embolism. In contrast, nonmobile cardiac myxomas with a round regular shape are rarely considered to be a cause of cerebral embolism. In this case, we present a patient with recurrent cerebral embolism associated with a small and nonmobile cardiac myxoma of round regular shape. CASE PRESENTATION: A 76-year-old Japanese man presented to our hospital with weakness in his right upper extremity. He had a history of right frontal lobe infarction in the previous month. T2-weighted magnetic resonance imaging revealed an area of hyperintensity in the left precentral gyrus, indicating acute cerebral infarction. Transthoracic echocardiography revealed normal left ventricular function and no abnormalities. However, transesophageal echocardiography showed a small and nonmobile left atrial tumor with round regular shape attached to the ostium secundum of the atrial septum. Based on these findings, we diagnosed recurrent cerebral infarction due to embolization caused by left atrial myxoma, and cardiac tumor extraction was performed on hospitalization day 36. The excised tumor measured 0.6 × 0.6 × 0.5 cm and was diagnosed as cardiac myxoma by histologic examination. CONCLUSIONS: Even small and nonmobile cardiac myxomas with a round regular shape may cause recurrent cerebral infarction. The diagnosis of this type of atrial myxoma is elusive and transesophageal echocardiography was an effective method of detection. In a clinical situation, this type of cardiac myxoma may be overlooked as a cause of cerebral infarction.

Relation between Resting State Front-Parietal EEG Coherence and Executive Function in Parkinson's Disease.

Objective. To assess the relation between executive dysfunction (ED) in Parkinson's disease (PD) and resting state functional connectivity evaluated using electroencephalography (EEG) coherence. Methods. Sixty-eight nondemented sporadic PD patients were assessed using the Behavioural Assessment of the Dysexecutive Syndrome (BADS) to evaluate executive function. EEG coherence in the left frontoparietal electrode pair (F3-P3) and the right frontoparietal electrode pair (F4-P4) was analyzed in the alpha and theta range. The BADS scores were compared across the coherence groups, and the multiple logistic regression analysis was performed to assess the contribution of confounders. Results. The standardized BADS score was significantly lower in the low F3-P3 coherence group in the alpha range (Mann-Whitney U test, p = 0.032), though there was no difference between F4-P4 coherence group in the alpha range, F3-P3, and F4-P4 coherence groups in the theta range and the standardized BADS score. The multiple logistic regression analysis revealed the significant relation between the F3-P3 coherence group in alpha range and age-controlled standardized BADS score (p = 0.039, 95% CI = 1.002-1.062). Conclusion. The decrease in resting state functional connectivity between the frontal and parietal cortices especially in the left side is related to ED in PD.

Surgically Cured, Relapsed Pneumococcal Meningitis Due to Bone Defects, Non-invasively Identified by Three-dimensional Multi-detector Computed Tomography.

A 43-year-old Japanese man presented with a history of bacterial meningitis (BM). He was admitted to our department with a one-day history of headache and was diagnosed with relapse of BM based on the cerebrospinal fluid findings. The conventional imaging studies showed serial findings suggesting left otitis media, a temporal cephalocele, and meningitis. Three-dimensional multi-detector computed tomography (3D-MDCT) showed left petrous bone defects caused by the otitis media, and curative surgical treatment was performed. Skull bone structural abnormalities should be considered a cause of relapsed BM. 3D-MDCT was useful for revealing the causal minimal bone abnormality and performing pre-surgical mapping.