Successful Reperfusion with Endovascular Therapy Has Beneficial Effects on Long-Term Outcome Beyond 90 Days.

BACKGROUND AND PURPOSE: Recent studies have demonstrated that endovascular reperfusion therapy improves clinical outcomes at 90 days after ischemic stroke. However, the effects on long-term outcomes are not well known. We hypothesized that successful reperfusion might be associated with long-term improvement beyond 90 days after endovascular therapy. To assess the long-term effects beyond 90 days, we analyzed the association of successful reperfusion with a temporal change in modified Rankin Scale (mRS) score from 90 days to 1 year after endovascular therapy. METHODS: We retrospectively analyzed a database of consecutive patients with acute ischemic stroke who received endovascular therapy between April 2006 and March 2016 at 4 centers. We compared the incidences of improvement and deterioration in patients with successful reperfusion (i.e., modified thrombolysis in cerebral infarction score of 2b or 3) with those in patients with unsuccessful reperfusion. We defined improvement and deterioration as decrease and increase on the mRS score by 1 point or more from 90 days to 1 year after endovascular therapy respectively. RESULTS: A total of 268 patients were included in the current study. The rate of patients with improvement tended to be higher in patients with successful reperfusion than in patients with unsuccessful reperfusion (20% [34/167 patients] vs. 12% [12/101], p = 0.07). The rate of patients with deterioration was lower in patients with successful reperfusion than in patients with unsuccessful reperfusion (25% [42/167] vs. 42% [42/101], p < 0.01). After adjustment for confounders, successful reperfusion was associated with improvement (adjusted OR 2.65; 95% CI 1.23-5.73; p < 0.05) and deterioration (adjusted OR 0.33; 95% CI 0.18-0.62; p < 0.01), independent of the 90-day mRS score. CONCLUSIONS: Successful reperfusion has further beneficial legacy effects on long-term outcomes beyond 90 days after stroke.

Intracardiac Thrombus Following Rivaroxaban Treatment in a Patient with Atrial Fibrillation Associated with Rheumatic Heart Disease.

We report a case of atrial fibrillation with rheumatic heart disease (RHD) who had intracardiac thrombus and cardiogenic cerebral embolism with rivaroxaban therapy. Intracardiac thrombus disappeared after switching from rivaroxaban to warfarin. Patients of RHD have the possibility of gradual progression of valvular disease even if they are old, so we need to distinguish nonvalvular atrial fibrillation from RHD before starting direct oral anticoagulants.

Carotid artery dissection associated with an elongated hyoid bone.

A 36-year-old man presented with acute cerebral infarction in the right frontal lobe associated with right internal carotid artery dissection (CAD). Enhanced computed tomography revealed right greater horn of the hyoid bone in close proximity to the right internal carotid artery (ICA). It was speculated that mechanical compression of the internal carotid artery by the hyoid bone induced by neck rotation was related to ICA dissection. Greater knowledge of the association between the hyoid bone and the CAD will lead to increased awareness and appropriate diagnosis.

First-in-human trial of a self-expandable, temporary dilation system for intracranial atherosclerotic disease in patients presenting with acute ischemic stroke.

BACKGROUND: Intracranial atherosclerotic disease (ICAD) significantly contributes to ischemic stroke, especially among Asian populations. Large vessel occlusion (LVO) due to underlying ICAD accounts for 15-35% of acute ischemic stroke cases requiring endovascular therapy. However, the successful recanalization rate of ICAD-related LVO remains lower. The TG dilator is a self-expandable device, temporarily dilating ICAD-related blocked blood vessels. OBJECTIVE: To demonstrate TG dilator safety and efficacy for ICAD-related acute ischemic stroke. METHODS: This was a single-arm, open-label, non-randomized, prospective, multicenter, and investigator-initiated trial that involved patients undergoing TG dilator application for acute ischemic stroke caused by ICAD-related LVO or severe stenosis. RESULTS: We enrolled 10 patients in this trial between November 2022 and April 2023. The median (IQR) age was 68 (59.3-75.3) years. Before using the dilator, seven patients received stent retriever treatment. All 10 patients were prescribed a loading dose of aspirin with prasugrel. The median application time was 10 (10-12) min. At the end of the procedure, we achieved significant recanalization immediately in all patients. The stenosis/occlusion decreased from 100% (100-100) to 68% (56.3-75.3). No patient experienced recurrent ischemic stroke or reocclusion within 90 days. We achieved a modified Rankin scale score of 0-2 in 8 patients by day 90. We detected no cases of intracranial hemorrhage, equipment failure, distal embolism, vasospasm, dissection, or perforation requiring intervention. CONCLUSIONS: Acute revascularization using the TG dilator on patients with ICAD-related LVO or severe stenosis did not cause any significant adverse event, and consistently improved blood flow at 90 days.

[Subacute encephalitis associated with anti-glutamate receptor antibodies: serial studies of MRI, 1H-MRS and SPECT].

A 32-year-old man who had experienced fever and a pulsating headache of the right occipital region for a month and a transient left hemianopia and numbness in the left arm two weeks prior to presentation was admitted to our hospital because of a seizure. Fluid-attenuated inversion recovery and diffusion-weighted magnetic resonance imaging (MRI) showed high-intensity signals, without reduction of apparent diffusion coefficient value, in the right temporo-occipital cortices. Proton MR spectroscopy (1H-MRS) indicated a decrease in N-acetylaspartate, and single-photon emission CT (SPECT) showed hyperperfusion in the right temporo-occipital territory. An examination of the cerebrospinal fluid showed an elevation of mononuclear cells and the presence of anti-glutamate epsilon2 receptor antibodies. All abnormalities shown by these imaging techniques were normalized in the clinical course. This report suggests that MRI, 1H-MRS and SPECT studies were useful in understanding the pathogenesis of encephalitis associated with glutamate receptor antibodies.

[Comparative analysis of learning effect for students who experienced both lecture-based learning and problem-based learning in a complete denture course].

PURPOSE: The purpose of this study was to analyze the difference in educational effect on students who experienced both lecture-based learning (LBL) and problem-based learning (PBL) in a complete denture course. The analysis focused on differences between the two methods concerning self study, ability to understand clinical inference, and appraisal of class contents and tutors. METHODS: In the complete denture preclinical course, the class of 2003 received LBL in 3rd grade and PBL in 4th grade. PBL was planned to present five cases in five consecutive classes. Group discussion was carried out for each case, and a summary was required to be produced two times as a group, two times as an individual report and one time by group presentation. A questionnaire regarding the educational effect of LBL and PBL and assessment of tutors was administered. Factor analysis was carried out to classify the questionnaire items and each item was analyzed between LBL and PBL (Paired-t test). RESULTS: Factor analysis revealed that the questionnaire items could be classified into four components. Comparing lecture type and PBL: "study attitude" (4 out of 7 items), "clinical inference ability" (all items), "class contents" (5 out of 7 items) and "tutor appraisal" (2 out of 5 items) showed significant assessment with PBL. Eighteen of 27 items (66.6%) indicated the significant usefulness of PBL. CONCLUSION: PBL improves the educational effect of self study and clinical inference ability, in comparison with LBL. However, since students are passive about taking the same system class repeatedly, a strategy to improve their attitude needs to be considered.

A case of recanalization of innominate artery and right middle cerebral artery embolism due to cardiogenic cerebral infarction with anticoagulation therapy.

An 80-year-old woman had an aortic valve replacement 1 month before admission and took warfarin for transient atrial fibrillation. She developed a disturbance of consciousness and left hemiplegia. On admission, the right radial artery was slightly palpable. Head MRI images showed a hyper-intense area in the right middle cerebral artery territory. MRA images showed an occlusion of the right M1 distal site and decreased signal at the right internal carotid artery. Contrast CT images of the ascending aorta showed an embolus in the innominate artery. She was diagnosed with an innominate artery saddle embolus and occlusion of the right cerebral artery due to cardiac embolism. She was treated with a heparin infusion and warfarin. She recovered consciousness and from hemiplegia gradually. Recanalization of the innominate artery and right cerebral artery was confirmed. In cases where the radial artery is slightly palpable, it is necessary to consider an innominate artery saddle embolus in addition to aortic dissection.

Stenting for acute cerebral venous sinus thrombosis in the superior sagittal sinus.

Endovascular treatment for superior sagittal sinus (SSS) thrombosis is not always successful because of difficult access and long thrombus lesions. We report the first two cases of patients with acute cerebral venous sinus thrombosis at the SSS that was not recanalized by anticoagulation, mechanical thrombectomy, or thrombolysis, but was successfully treated by stent placement. Case 1 was a 37-year-old woman with bilateral subdural hematomas. Digital subtraction angiography showed obstruction of the sinus from the SSS to the right transverse sinus. Recanalization was achieved by selective thrombolysis using urokinase followed by balloon angioplasty, but re-occlusion occurred on the next day of treatment. Repeated endovascular treatment including balloon angioplasty, thrombus aspiration and thrombolysis using recombinant tissue plasminogen activator failed to achieve recanalization. We thus placed intracranial stents in the SSS, which did achieve recanalization. Case 2 was a 69-year-old woman with a small infarction in the left parietal lobe. Digital subtraction angiography showed sinus obliteration from the SSS to the bilateral transverse sinuses. Recanalization was not achieved by balloon angioplasty, thrombus aspiration and selective thrombolysis. We thus placed intracranial stents in the SSS, which did achieve recanalization. Postoperative course was uneventful in both cases and venous sinus patency was confirmed by venography >1.5 years after treatment. When conventional endovascular strategies have been unsuccessful, placement of intracranial stents, which can easily gain access to the distal part of the SSS as compared with carotid stents, may be a useful treatment option for the acute sinus thrombosis in this region.

[Multiple cerebral infarctions in a patient with hypereosinophilic syndrome with Löffler endocarditis: a case report].

An 82-year-old woman with a history of asthma was admitted to our hospital because of dyspnea. On admission, laboratory testing showed a white blood cell count of 17,700/µl with hypereosinophilia of 9,204/µl (52% of all white blood cells). Various examinations, including a bone marrow biopsy for the cause of eosinophilia, were unremarkable. The patient was diagnosed with hypereosinophilic syndrome (HES). Treatment with intravenous methylprednisolone was initiated. The patient's eosinophil count normalized within 1 day. On the 6th day, she developed left-sided hemiparesis. Magnetic resonance imaging (MRI) of the brain showed acute multiple infarcts in arterial border zones of bilateral cerebral and cerebellar hemispheres, and in bilateral basal ganglia and the thalamus. Magnetic resonance angiography was normal. Coagulation factors were normal, except for an elevated D-dimer level (12.9 µg/ml). A transthoracic echocardiogram showed thickening of the left ventricular endocardium with immobile thrombus, compatible with Löffler endocarditis. Treatment with oral prednisolone was started at 30 mg/day and then tapered to a maintenance dose of 5 mg/day. Anticoagulation was concurrently started for prevention of stroke. Ten months later, an echocardiogram showed that the thrombus had decreased in size, and MRI revealed no new cerebral infarctions. The cause of cerebral infarction in patients with hypereosinophilia is thought to be thromboembolism or cerebrovascular endothelial toxicity of eosinophils. In this patient, the cerebral infarcts may have been the result of embolism from the left ventricular thrombus. Because HES with Löffler endocarditis is frequently associated with a poor prognosis, cardiovascular problems should be evaluated and treatment started as soon as possible.

Imaging of distal internal carotid artery by ultrasonography with a 3.5-MHz convex probe.

BACKGROUND AND PURPOSE: Conventionally, carotid ultrasonography has been performed with a 7.5-MHz linear probe to evaluate the extracranial internal carotid artery (ICA). However, usually only the carotid bulb or proximal portion of the ICA can be evaluated. We attempted to evaluate the distal extracranial ICA with a 3.5-MHz convex probe. METHODS: The subjects were 17 consecutive patients with ICAs free of occlusive disease and 3 other patients with distal extracranial ICA stenosis. Using a 7.5-MHz linear probe and a 3.5-MHz convex probe, we performed long-axis B-mode imaging of the ICAs to evaluate the distance between the distal limit of visualized ICA and the bifurcation of the common carotid artery. RESULTS: The distal limit of the ICA, visualized with a 7.5- or a 3.5-MHz probe, was 31+/-11 or 57+/-8 mm distal to the common carotid artery bifurcation, respectively. In the 3 patients with distal extracranial ICA stenosis, the lesion could be successfully diagnosed with only the 3.5-MHz probe. CONCLUSIONS: This form of carotid imaging is feasible and may be potentially useful in the evaluation of carotid disease.

Correlation of angiographic circulation time and cerebrovascular reserve by acetazolamide-challenged single photon emission CT.

BACKGROUND AND PURPOSE: Although cerebral circulation time (CCT) is one of the main parameters in cerebral blood flow measurements, its clinical significance is controversial. To assess the importance of CCT by using a nondiffusible indicator, we studied the relationship between angiographic CCT and cerebrovascular reserve. METHODS: Twenty-eight patients, each with a unilateral occlusive lesion in the internal carotid artery or middle cerebral artery, were examined. To assess the CCT, the regional arteriocapillary circulation time (rACCT) was measured by angiography and the ratio of the value on the occlusive side to the value on the contralateral side was calculated as the rACCT ratio. To estimate the cerebrovascular reserve, acetazolamide-challenged single photon emission CT was used. Patients with a decreased cerebrovascular reserve were defined as the "poor reserve" group, and those without a decrease were defined as the "normal reserve" group. The ratio of the radioactivity count on the occlusive side to the count on the contralateral side was calculated as the asymmetry index, and the proportion of the acetazolamide-challenged asymmetry index to the baseline asymmetry index was defined as the regional reactivity index. RESULTS: The rACCT ratio in the poor reserve group (n = 19) was significantly (P <.001) larger than that in the normal reserve group (n = 9), and a significant correlation (r = -0.83, P <.01) was found between the rACCT ratio and the regional reactivity index. CONCLUSION: The angiographic CCT and the cerebral vasoreactivity to acetazolamide on single photon emission CT were well correlated, suggesting that measurement of the CCT by using a nondiffusible indicator could be used as an index of cerebrovascular reserve.

Prognostic value of subacute crossed cerebellar diaschisis: single-photon emission CT study in patients with middle cerebral artery territory infarct.

BACKGROUND AND PURPOSE: Although chronic-stage crossed cerebellar diaschisis (CCD) is reported to be associated with the neurologic state or clinical improvement after infarct, the prognostic value of early-stage CCD remains controversial. Our aim was to determine whether measurements of CCD in the acute and subacute stages obtained at single-photon emission CT (SPECT) facilitate the prediction of stroke outcome. METHODS: The pattern of cerebral blood flow changes after the occurrence of acute middle cerebral artery ischemia with severe cortical symptoms was examined by using technetium 99m-hexamethylpropyleneamine oxime ((99m)Tc-HMPAO) SPECT. Fifteen patients (mean age, 73 years +/- 8 [SD]) with unilateral ischemia were examined in the early subacute stage (10 days +/- 5). In 11 patients, SPECT was performed in both the acute (16 hours +/- 10) and subacute stages. From the total counts obtained from each cerebellar hemisphere, the asymmetry index (AI) was calculated as follows: [(value in unaffected hemisphere--value in affected hemisphere)/value in unaffected hemisphere] x 100. Clinical outcome (at 60 days) was assessed by means of the Scandinavian Stroke Scale (SSS) and Barthel Index (BI). RESULTS: AIs in the acute stage and clinical outcome (ie, SSS and BI scores) showed no significant correlation, but the severity of AI in the early subacute stage correlated significantly with both the final SSS (r = -0.69; P <.01) and BI scores (r = -0.82; P <.01). CONCLUSION: Cerebellar hypoperfusion detected at (99m)Tc-HMPAO SPECT in the early subacute stage in patients with supratentorial infarct indicates a worse clinical outcome.

Correlation of middle cerebral artery tortuosity with successful recanalization using the Merci retrieval system with or without adjunctive treatments.

The Merci retrieval system is a useful modality for the recanalization of acute cerebral artery occlusion. However, it remains unclear whether the tortuosity of the middle cerebral artery (MCA) plays a role in successful recanalization. In this study, we investigated the association between the shape of the horizontal MCA segment (M1) and successful recanalization using the Merci retrieval system with or without adjunctive treatments. Twenty-three patients with M1 occlusion underwent thrombectomy using the Merci retrieval system with or without adjunctive treatments between July 2010 and July 2012. The anteroposterior view of final angiograms was used to measure the M1 curve angles. M1 with a curve angle measuring < 100° was defined as arch-type M1, whereas that with a curve angle measuring ≥ 100° was defined as straight-type M1. Angiographic findings were evaluated on the basis of the thrombolysis in cerebral infarction grade; grade 2B or 3 corresponds to successful recanalization. Eight patients had arch-type M1 and 15 patients had straight-type M1. Successful recanalization was achieved in 2 patients (25%) with arch-type M1 and 12 patients (80%) with straight-type M1 (p = 0.023). The mean M1 curve angle was significantly greater in the 14 patients in whom successful recanalization was achieved than in the 9 patients in whom it was not achieved (129 ± 21° vs. 93 ± 29°, p = 0.002). Arch-type M1 was an independent predictive factor of unsuccessful recanalization (odds ratio, 0.045; 95% confidence interval, 0.03-0.696). A tortuous M1 was associated with unsuccessful recanalization by the Merci retrieval system, even when adjunctive treatments were used.

[Primary central nervous system lymphoma mimicking ventriculitis].

A 66-year-old man presented with deteriorated bradykinesia, gait disturbance, disorientation, and urinary incontinence for three weeks. Magnetic resonance imaging (MRI) showed dilatation of the ventricles. Cerebrospinal fluid (CSF) examination demonstrated lymphocytic pleocytosis, elevation of protein levels, and decreased of glucose levels. A gadolinium-enhanced MRI revealed lesions in the ventricular wall and choroid plexus, mimicking ventriculitis. No evidence of bacterial, fungal, mycobacterial, or viral infections were observed in the CSF. Flow cytometry of CSF showed predominance of CD20+, λ+ cells. PCR examination of CSF revealed positive IgH gene rearrangement, suggesting B cell lymphoma. Endoscopic brain biopsy showed diffuse large B cell lymphoma. As the patient had no evidence of lymphoma in the other organs, we made a diagnosed of primary central nervous system lymphoma (PCNSL). A limited intraventricular spread of PCNSL is rare but important as one of differential diagnosis of ventriculitis.

[Paradoxical brain embolism mediated through a pulmonary arteriovenous malformation with hereditary hemorrhagic telangiectasia in a Japanese patient].

We report a case of paradoxical brain embolism mediated through a pulmonary arteriovenous malformation (PAVM) with hereditary hemorrhagic telangiectasia (HHT). A 25-year-old right handed man was admitted to our hospital after sudden headache and visual field abnormality. In neurologic examinations, he had left superior-quadrantanopsia. Laboratory findings showed iron deficiency anemia. Diffusion weighted images disclosed a high-signal-intensity area in the right occipito-temporal lobe, and intraarterial digital subtraction cerebral angiography revealed occlusion of the right posterior cerebral artery. Transesophageal echocardiography revealed continuous right-to-left shunt. We confirmed his history of spontaneous recurrent epistaxis and the first-degree relatives with epistaxis or PAVM. A contrast enhanced CT scan of the chest revealed a PAVM. The diagnosis of paradoxical brain embolism mediated through the PAVM with HHT was, thus, established. The PAVM was occluded by using embolization coils successfully. In Asian countries, the prevalence of PAVM with HHT is thought to be lower than in European countries. We should carefully take medical and family histories, especially epistaxis, in a young stroke patient.

Case reports of unexpected suicides in patients within six months after stroke.

Suicide after stroke is a grievous occurrence. Since the majority of cases under study had shown signs of recovery from stroke, persons surrounding these patients were severely shocked by these suicides. Six patients who attempted suicide within six months after stroke were investigated to determine factors following stroke that relate to suicide in order to prevent future post-stroke suicides. Clinical findings in these six cases were retrospectively analyzed in collaboration with stroke neurologists and coworkers caring for these patients. Four of six patients had sustained a recent infarction extending from the temporal cortex to the parietal cortex. Four of six patients showed depression, and five of six patients showed moderate disability after stroke. Physicians should carefully observe patients with infarction extending from the temporal cortex to the parietal cortex, depression and moderate disability, in order to prevent suicidal behavior.

Lacunar syndrome associated with paradoxical brain embolism.

We report a patient who developed lacunar syndrome due to left upper pons infarction after performing leg exercises associated with paradoxical brain embolism. A 32-year-old man developed right arm weakness and moderate dysarthria following leg exercise. Brain MRI showed a paramedian pontine infarction of the left upper pons, and contrast transesophageal echocardiographic examination indicated that the patent foramen ovale was the embolic source. Simultaneous RI venography examination of the lower limbs identified deep venous thrombosis in the right leg as a paradoxical emboligenic source. We concluded that the presence of lacunar syndrome suggests that this mechanism was responsible for the paradoxical brain embolism.