Ischemic stroke patients with low DWI ASPECTS scores require puncture to recanalization within 30 min for large vessel occlusion.

BACKGROUND: The clinical benefits of faster recanalization in acute large vessel occlusion are well recognized, but the optimal procedure time remains uncertain. The aim of this study was to identify patient characteristics that necessitate puncture-to-recanalization (P-R) time within 30 min to achieve favorable outcome. METHODS: We evaluated the patients from a prospective, multicenter, observational registry of acute ischemic stroke patients. The study included patients who underwent endovascular therapy for ICA or MCA M1 occlusion and achieved successful recanalization. Patients were categorized into subgroups based on pre-treatment characteristics and the frequency of favorable outcomes was compared between P-R time < 30 min and ≥ 30 min. Interaction terms were incorporated into the models to assess the correlation between each patient characteristic and P-R time. RESULTS: A total of 1053 patients were included in the study. Univariate analysis within each subgroup revealed a significant association between P-R < 30 min and favorable outcomes in patients with DWI ASPECTS ≤6, age > 85 and NIHSS ≥16. In the multivariable analysis, NIHSS, age, time from symptom recognition to puncture, and DWI ASPECTS were significant independent predictors of favorable outcomes. Notably, only DWI ASPECTS exhibited interaction terms with P-R < 30 min. The multivariable analysis indicated that P-R < 30 min was an independent predictor for favorable outcome in DWI ASPECTS ≤6 group, whereas not in DWI ≥7. CONCLUSIONS: P-R time < 30 min is predictive of favorable outcomes; however, the effect depends on DWI ASPECTS. Target P-R time < 30 min is appropriate for patients with DWI ASPECTS ≤6.

Efficacy and safety of thrombectomy for acute ischaemic stroke in patients with pre-stroke mRS scores of 2-3: Real-world evaluation from an open-label, prospective, multicentre, observational study.

BACKGROUND: This study assessed the efficacy and safety of thrombectomy for acute ischaemic stroke in a population with pre-stroke modified Rankin scale (mRS) scores of 2-3 using real-world data. METHODS: Our sample set included 2313 consecutive patients enrolled in the Kanagawa Registry of Intravenous and Endovascular Treatment of Acute Ischemic Stroke registry between January 2018 and June 2020 in 40 stroke centres in Kanagawa Prefecture, Japan. Patients treated with intravenous tissue plasminogen activator (t-PA), thrombectomy, or both were included. Patients with pre-stroke mRS scores of 4-5 and those treated only with intra-arterial thrombolysis were excluded. The primary outcome of this study was an mRS score of 0-3 at 90 days after onset to assess the efficacy of thrombectomy for pre-stroke disabled individuals. We performed multivariate logistic regression analyses to investigate independent factors for a 90-day mRS score of 0-3. We also performed nearest-neighbour within-calliper matching between thrombectomy and t-PA only. RESULTS: After excluding patients meeting the exclusion criteria, we analysed data of 2136 consecutive patients, of which 315 (14.7%) had pre-stroke disabilities (mRS score 2-3). A 90-day mRS score of 0-3 was achieved by 33.3% of patients with pre-stroke mRS scores of 2-3. According to multivariate analysis, the National Institutes of Health Stroke Scale (NIHSS) score was an independent factor. Furthermore, after propensity-score matching, thrombectomy showed considerable superiority for achieving a 90-day mRS score of 0-3. CONCLUSION: Intravenous t-PA and especially thrombectomy were safe and effective for the population with pre-stroke disabilities, particularly for patients with low NIHSS scores.

Increased door-to-puncture time during off-duty hours results in poor treatment outcomes for acute ischemic stroke: A subanalysis of the K-NET registry.

BACKGROUND: For patients who undergo endovascular treatment for acute ischemic stroke, the total time for treatment may increase during off-duty hours leading to worse outcomes. The present study compared endovascular treatment outcomes for on-duty and off-duty hours and examined factors that could be responsible for the prolonged treatment of patients in a multicenter registry. METHODS: The study group comprised 1571 patients listed in the multicenter stroke registry (K-NET) who had undergone endovascular treatment between January 2018 and June 2020. The modified Rankin Scale (mRS), evaluated at 90 days after stroke onset, was utilized as the primary outcome. Patients were divided into on-duty and off-duty patients based on admission time. Multivariate logistic regression analysis was used to identify the independent factors that increased the time from admission to puncture during the off-duty period. RESULTS: The mean mRS score at 90 days after stroke onset was 2.9, similar in both on-duty and off-duty patients, with no significant difference (p = 0.77); however, significant differences were observed in time from door-to-puncture (74.7 vs. 88.8, p < 0.01). Additionally, the mRS score at 90 days worsened significantly for door-to-puncture time >60 min in the off-duty period. Multivariate logistic regression analysis revealed that a low National Institute of Health Stroke Scale (NIHSS) score, high pre-mRS score, posterior circulation, and diabetes were independent indicators of door-to-puncture time >60 min during the off-duty period. CONCLUSION: Door-to-puncture time >60 min during off-duty hours was associated with poor outcomes related to low NIHSS, high pre-mRS, posterior circulation, and diabetes.

Primary results of mechanical thrombectomy for acute ischemic stroke: The K-NET registry in the Japanese metropolitan area.

BACKGROUND: Endovascular treatment (EVT) for acute large vessel occlusion has proven to be effective in randomized controlled trials. We conducted a prospective cohort study to evaluate the real-world efficacy of EVT in a metropolitan area with a large number of comprehensive stroke centers and to compare it with the results of other registries and randomized controlled trials (RCTs). METHODS: We analyzed the Kanagawa Intravenous and Endovascular Treatment of Acute Ischemic Stroke registry, a prospective, multicenter observational study of patients treated by EVT and/or intravenous tissue-type plasminogen activator (tPA). Of the 2488 patients enrolled from January 2018 to June 2020, 1764 patients treated with EVT were included. The primary outcome was a good outcome, which was defined as a modified Rankin Scale (mRS) of 0-2 at 90 days. Secondary analysis included predicting a good outcome using multivariate logistic regression analysis. RESULTS: The median age was 77 years, and the median National Institute of Health Stroke Scale (NIHSS) score was 18. Pretreatment mRS score 0-2 was 87%, and direct transport was 92%. The rate of occlusion in anterior circulation was 90.3%. Successful recanalization was observed in 88.7%. The median time from onset to recanalization was 193 min. Good outcomes at 90 days were 43.3% in anterior circulation and 41.9% in posterior circulation. Overall mortality was 12.6%. Significant predictors for a good outcome were as follows: age, male, direct transfer, NIHSS score, Alberta Stroke Program Early Computed Tomography Score, intravenous tPA, and successful recanalization. CONCLUSION: EVT in routine clinical use in a metropolitan area showed comparable good outcomes and lower mortality compared to previous studies, despite the high proportion of patients with older age, pretreatment mRS score of >2, posterior circulation occlusion, and higher NIHSS. Those results may have been associated with more direct transport and faster onset-to-recanalization times.

Evaluating the roles of the inferior frontal gyrus and superior parietal lobule in deductive reasoning: an rTMS study.

This study used off-line repetitive transcranial magnetic stimulation (rTMS) to examine the roles of the superior parietal lobule (SPL) and inferior frontal gyrus (IFG) in a deductive reasoning task. Subjects performed a categorical syllogistic reasoning task involving congruent, incongruent, and abstract trials. Twenty four subjects received magnetic stimulation to the SPL region prior to the task. In the other 24 subjects, TMS was administered to the IFG region before the task. Stimulation lasted for 10min, with an inter-pulse frequency of 1Hz. We found that bilateral SPL (Brodmann area (BA) 7) stimulation disrupted performance on abstract and incongruent reasoning. Left IFG (BA 45) stimulation impaired congruent reasoning performance while paradoxically facilitating incongruent reasoning performance. This resulted in the elimination of the belief-bias. In contrast, right IFG stimulation only impaired incongruent reasoning performance, thus enhancing the belief-bias effect. These findings are largely consistent with the dual-process theory of reasoning, which proposes the existence of two different human reasoning systems: a belief-based heuristic system; and a logic-based analytic system. The present findings suggest that the left language-related IFG (BA 45) may correspond to the heuristic system, while bilateral SPL may underlie the analytic system. The right IFG may play a role in blocking the belief-based heuristic system for solving incongruent reasoning trials. This study could offer an insight about functional roles of distributed brain systems in human deductive reasoning by utilizing the rTMS approach.

Cavernous angioma of the vestibular nerve: case report and literature review.

BACKGROUND: To date, 50 cases of cavernous angioma in the CPA have been reported, and previous reports did not describe the tumor's site of origin. We describe a case of a small, extraaxial cavernous angioma of the vestibular nerve. We also propose a reclassification system for cavernous angioma of the CPA based on the tumor's site of origin. CASE DESCRIPTION: A 39-year-old female patient had recurrent deteriorating vertigo and a right hearing disturbance. Magnetic resonance imaging revealed a cavernous angioma of the right CPA. Surgery was performed through a right lateral suboccipital approach. In the present case, the mass was attached to and covered the cisternal portion of the vestibular nerve, and it contained microvessels that were fed from the vascular plexus of the vestibular nerve. The tumor was resected en bloc, and the microvessels feeding it were cauterized. CONCLUSIONS: On the basis of our review of 50 cases of cavernous angioma of the CPA, we propose that these tumors can be classified according to whether they develop from the venous plexus of the dura matter or of a cranial nerve. We also suggest that the site of origin affects the postoperative symptoms.

Lipomatous meningioma.

We present a case of intracranial lipomatous meningioma in the parietal convexity in a 64-year-old woman. The mass showed low density on computed tomography, was hyper-intense on T1-weighted magnetic resonance images, and had decreased intensity upon imaging with fat-suppressed sequences. Gross total removal of the tumor was performed. Histopathologically, the tumor was a meningioma with mixed transitional and lipomatous patterns. Immunohistochemically, the meningothelial foci were positive for epithelial membrane antigen (EMA) and vimentin, and negative for S-100 protein. The lipomatous foci were positive for EMA, vimentin, and S-100 protein. The Ki-67 index values of the meningothelial and lipomatous foci were 1.0% and 1.8%, respectively. We review previous reports of lipomatous meningioma and discuss its clinical presentations and pathology.

Chronic Encapsulated Intracerebral Hematoma: Endoscopic Removal as Minimally Invasive Surgery for a Patient with Alcoholic Cirrhosis.

Chronic encapsulated intracerebral hematoma (CEIH) is a rare cerebrovascular disease. Here, we describe a case of a patient with alcoholic cirrhosis and an abnormal coagulation state that was treated with minimally invasive endoscopic hematoma removal. A 54-year-old man presented with a 2-week history of incoherent speech, incontinence, and repeated stumbling. Laboratory analysis showed thrombocytopenia and the prolongation of prothrombin time due to alcoholic cirrhosis. Computed tomography and magnetic resonance imaging showed a large mass in the left parieto-occipital lobe suggesting a hematoma. Minimally invasive endoscopic hematoma removal was then performed. CEIH was diagnosed from the intraoperative findings of serous hematoma, a thin yellowish capsule, and old clots. The postoperative course was uneventful and there was no hematoma recurrence. In conclusion, endoscopic hematoma removal may be one of the options for the treatment of CEIH in patients with cirrhosis and an abnormal coagulation state.

Intrasellar salivary gland-like pleomorphic adenoma: case report.

BACKGROUND AND IMPORTANCE: We present a rare case of a patient with intrasellar salivary gland-like pleomorphic adenoma and review the 2 previously reported cases of the clinical entity to identify their common clinical features. CLINICAL PRESENTATION: A 56-year-old Asian man visited our hospital with a chief complaint of visual disturbance caused by brain tumor that filled up the sella turcica with suprasellar extension. The patient underwent craniotomy via a left pterional approach, and the subdural, intracranial portion of the tumor was totally removed, with every artery and nerve preserved. Pathological diagnosis of the tumor was intrasellar salivary gland-like pleomorphic adenoma. Three years after the operation, the patient remains free from tumor recurrence. CONCLUSION: Tumors in all 3 reported cases of intrasellar salivary gland-like pleomorphic adenoma, including the present case, showed suprasellar extension and compressed optic chiasm that resulted in visual disturbance of the patients. A calcified region inside the tumor on computed tomographic scanning was also a common finding. Differential diagnosis of intrasellar salivary gland-like pleomorphic adenomas should be considered in patients with calcified intrasellar tumors with suprasellar extension. The clinical entity seems to show good prognosis if surgically removed.

Severe parkinsonism following endoscopic third ventriculostomy for non-communicating hydrocephalus--case report.

A 23-year-old male with non-communicating hydrocephalus caused by intraventricular hemorrhage from an arteriovenous malformation was treated by endoscopic third ventriculostomy (ETV) after repeated ventricular cerebrospinal fluid drainage and removal of ventriculoperitoneal shunt due to infection. Postoperatively, the patient developed robust rigidity and akinesia with mutism, suggesting secondary parkinsonism. These symptoms showed marked improvement after administration of levodopa, and were not aggravated after discontinuation. The pathophysiology of this case might involve dysfunction of the dopaminergic system caused by repeated compression and release of the paraventricular white matter. Careful perioperative management not leading to excessive dilation of the the ventricles should be considered for ETV for non-communicating hydrocephalus to avoid this unexpected complication.

The role of inferior frontal cortex in belief-bias reasoning: an rTMS study.

The belief-bias effect in syllogistic reasoning refers to the tendency for subjects to be erroneously biased when logical conclusions are incongruent with belief about the world. This study examined the role of inferior frontal cortex (IFC) in belief-bias reasoning using repetitive transcranial magnetic stimulation (rTMS). We used an off-line rTMS method to disrupt IFC activity transiently. Right IFC stimulation significantly impaired incongruent reasoning performance, enhancing the belief-bias effect. Subjects whose right IFC was impaired by rTMS may not be able to inhibit irrelevant semantic processing in incongruent trials. Although left IFC stimulation impaired congruent reasoning, it paradoxically facilitated incongruent reasoning performance, eliminating the belief-bias effect. Subjects whose left IFC was impaired by rTMS may not suffer from interference by irrelevant semantic processing. This study demonstrates for the first time the roles of left and right IFC in belief-bias reasoning using an rTMS approach.

Assessment of cognitive function before and after surgery for posterior cranial fossa lesions using computerized and conventional tests.

Cognitive function has not been well studied after neurosurgery for posterior fossa lesions despite its potential importance in determining surgical indications and approaches. The present study evaluated changes in cognitive functions after posterior fossa surgery to detect any differences between the middle cranial fossa and lateral suboccipital approaches in 50 patients with posterior fossa lesions such as tumors and vascular diseases. Twenty-five patients underwent surgery via the middle fossa and 25 via the lateral suboccipital approaches. Computerized test battery (CogState) and conventional neuropsychological tests (serial seven-word learning test and mini-mental state examination) were examined before, 1 month after, and 3 months after surgery. All scores of the neuropsychological tests remained within normal limits after surgery. However, the scores of one computerized test battery and serial seven-word learning tests decreased significantly 1 month after surgery and recovered within 3 months, indicating temporary deterioration of short-term memory in the middle fossa group. The computerized tests detected significantly larger numbers of patients with worsened results than the conventional tests. The middle fossa approach and operation time showed correlations with the postoperative neuropsychological declines. The computerized tests could be performed easily and were beneficial for detecting subtle changes of the cognitive function after surgery. Cognitive function, especially short-term memory, may decline temporarily with the middle fossa approach and long operation time.

Effects of sedative and nonsedative antihistamines on prefrontal activity during verbal fluency task in young children: a near-infrared spectroscopy (NIRS) study.

INTRODUCTION: Antagonists of histamine H(1) receptors (antihistamines) are widely used for the treatment of allergic disorders in children. These drugs' sedative effect on brain function, however, has been mostly examined in adults. OBJECTIVE: The objective of this study was to examine the effects of anitihistamines on prefrontal cortex activity in young children using near-infrared spectroscopy (NIRS), a novel brain-imaging method. MATERIALS AND METHODS: In 15 healthy children (mean age, 7.7 years), we examined changes of oxygenated hemoglobin concentration in the prefrontal cortex while they performed a verbal fluency task 3 h after taking a sedating antihistamine (ketotifen), nonsedating antihistamine (epinastine), or placebo. RESULTS: Ketotifen significantly impaired behavioral performance and cortical activation at the lateral prefrontal cortex compared with placebo. There were no sedative effects on neural response or behavioral performance after epinastine administration. CONCLUSIONS: NIRS revealed that sedating and nonsedating antihistamines exert differential effects on brain hemodynamic response in young children.