Intra-arterial fibrinolysis via the contralateral internal carotid artery for acute ischemic stroke.

We report a 65-year-old male who suddenly developed consciousness disturbance and left hemiplegia, with tandem embolic occlusions of the right internal carotid artery (ICA) and the middle cerebral artery (MCA). Intra-arterial administration of recombinant tissue plasminogen activator (rtPA) through the right ICA was performed 2.75 hours after onset, but no recanalization of the right ICA was obtained. Then rtPA was administrated from the left ICA, and the right MCA was recanalized 3 hours after onset. Our findings indicate that administration of rtPA through the contralateral internal carotid system could be an effective strategy for patients with tandem occlusions of the ICA and MCA if an anterior communicating artery is patent.

[Hemichorea improved by carotid artery stenting in a 73-year-old man with hypoperfusion of the basal ganglia].

A 73-year-old man presented with continuous hemichoreic movement of right arm and leg and with dyskinesia in his tongue. Magnetic resonance image (MRI) showed no ischemic lesion within the basal ganglia, but magnetic resonance angiography (MRA) and carotid duplex ultrasonography showed the left internal carotid occlusion and 80% stenosis in the right common carotid artery. Tc-99m-ECD-SPECT showed hypoperfusion of the frontal lobe, temporal lobe, parietal lobe, basal ganglia and thalamus. A trial of haloperidol had no effect; therefore, the right carotid artery stenting was performed. Hypoperfusion in the left internal carotid artery area was improved by cross flow from the right side, and his hemichorea gradually improved. This result supports the notion that hypoperfusion-related hemichorea may occur, even in the absence of cerebral ischemia.

[Masseter strength in patients with motor neuron disease].

Although masseter muscles play an essential role in digestion, masseter strength in patients with motor neuron diseases has not been well studied. The purpose of this study is to evaluate the masseter strength in healthy volunteers (n = 13, mean age +/- S.D.: 58 +/- 10 years) and in patients with motor neuron diseases (n = 16, mean age +/- S.D.: 61 +/- 10 years) using a device for the measurement of occlusal forces (Nihon Koden, Co. Ltd., Japan). Masseter strength values in the healthy volunteers and the patients with motor neuron diseases including amyotrophic lateral sclerosis (ALS) were 24.6 +/- 13.4 kg (mean +/- S.D.) and 21.9 +/- 16.4 kg (ALS: 26.2 +/- 14.6 kg), respectively, and this difference is not statistically significant. Further, there was no relation between masseter strength and the severity of clinical signs including bulbar palsy. These results suggest that masseter strength is not particularly vulnerable in patients with motor neuron diseases.

Significance of the presence of metabolic syndrome in patients with asymptomatic arteriosclerosis affecting the aorta and the cerebral, extra-cranial carotid and coronary arteries.

OBJECTIVE: The presence of metabolic syndrome (MetS) is strongly associated with stroke and cardiovascular diseases. However, the relationship between MetS and the localization of atherosclerosis at various sites remains uncertain. In this study, in order to reveal the relevance of MetS to atherosclerosis at several sites, we investigated the relationships among vascular risk factors, asymptomatic cerebral infarction and atherosclerosis in the aorta and carotid and coronary arteries in adults without overtly symptomatic cerebrovascular or cardiovascular disease. METHODS: The subjects in this study included 2,759 Japanese participants (1,845 men and 914 women, mean age: 52 years) with no history of stroke or cardiovascular events. The diagnosis of MetS was made based on modifications to criteria obtained from the National Cholesterol Education Program Adult Treatment Panel. In all subjects, the presence of cerebral infarction in the extra-cranial carotid, coronary and aortic arteries was investigated using MRI, B-mode ultrasonography and CT. RESULTS: Of the 2,759 subjects, 796 (28.9%) fulfilled the criteria for MetS. The presence of MetS increased the odds ratio (OR) to 1.89 (95% confidence interval (CI): 1.35-2.65, p-value <0.0001) for asymptomatic cerebral infarction, 1.70 (95% CI: 1.37-2.10, p-value <0.0001) for carotid arteriosclerosis, 2.07 (95% CI: 1.62-2.27, p-value <0.0001) for coronary calcification and 1.67 (95% CI: 1.33-2.09, p-value<0.0001) for aortic calcification. CONCLUSION: The presence of MetS was found to be significantly correlated with arteriosclerosis in all regions, including the cerebral small-vessels, extra-cranial carotid arteries, coronary arteries and abdominal aorta. MetS might be a predictor for small and large vessel disease throughout the body.

Early diagnosis of anti-N-methyl-D-aspartate receptor encephalitis in a young woman with psychiatric symptoms.

A previously healthy 21-year-old woman, transported to our medical emergency center for excluding organic brain disease, had undergone medical examination 9 days before for trembling in her left hand, which was caused by stress. The patient exhibited fever and strange behaviors, e.g., wandering around, babbling, and making smoking gestures; hence, psychiatric examination was performed. The patient's Glasgow Coma Scale score was 4-3-5, and involuntary movement was observed. Cerebrospinal fluid examination revealed increased cell count; hence, we suspected anti-N-methyl-d-aspartate (NMDA) receptor encephalitis. We conducted an abdominal CT scan, which revealed a neoplastic lesion with calcification in the right ovary. Early steroid pulse therapy was started. On hospital day 25, she tested positive for anti-NMDA receptor antibodies; hence, anti-NMDA receptor encephalitis and concomitant ovarian teratoma was diagnosid. She underwent right adnexectomy; subsequently, immunotherapy was performed. The patient recovered and was discharged on hospital day 105. Anti-NMDA receptor encephalitis is not uncommon; however, this disease must be considered for young encephalitis patients exhibiting psychiatric symptoms. If patients (aged ≤ 30 years) presents with encephalitis of uncertain etiology, psychiatric symptoms, seizures, movement disorders, or psychosis, clinicians should consider anti-NMDA encephalitis as a possible diagnosis. Clinical diagnosis should be waged early to ensure timely treatment.