Palatal prolapse during nasal expiration in patients with myasthenia gravis.

INTRODUCTION/AIMS: We have encountered patients with myasthenia gravis (MG) who exhibited palatal prolapse (PP) during nasal expiration in the supine position while awake. This may be an overlooked cause of dyspnea in MG patients. This study aimed to examine and describe the characteristics of MG patients with PP. METHODS: We reviewed the medical records of 183 consecutive patients who were diagnosed with MG in our hospital from 2012 to 2021. Thirty-two patients underwent laryngoscopy because of bulbar symptoms. Eight of these patients (25%) exhibited PP on laryngoscopy. Clinical features of these eight patients were retrospectively characterized. RESULTS: Median age of the eight patients with PP was 70 years. Six were men. Median body mass index was 21.6 kg/m2 . All patients exhibited PP in the supine position but not the sitting position. Although no patient had abnormal findings on spirometry nor chest computed tomography, six reported dyspnea or difficulty with nasal expiration only in the supine position. PP improved in all four patients who underwent edrophonium testing. All eight patients eventually improved after immunotherapy. DISCUSSION: PP during nasal expiration may be a cause of dyspnea in MG patients, along with respiratory muscle impairment, lung disease, and vocal cord paralysis. Laryngoscopy in the supine position is required to confirm.

[Acute myeloid leukemia diagnosed by dysphagia due to bilateral vagus nerve palsy: a case report].

This is the rare case report that bilateral vagus nerve paralysis was emerged as the initial symptom of acute myelogenous leukemia (AML). An 83-year-old man admitted to our hospital because of dysphagia. His dysphagia progressed two months prior to admission. Although physical examination revealed no abnormality, videoendoscopy and videofluorography examination clearly revealed bilateral vagus nerve palsy. Brain MRI showed hypointense signals at the bilateral clivus on T1 weighted images, suggesting tumor infiltration to bilateral petroclivus. He was diagnosed as AML by blood samples and bone marrow biopsy. After initiation of the treatment including radiation therapy, dysphagia shows mild improvement. Although bilateral cranial nerve palsy due to malignant tumor involving at the clivus is very uncommon, we should pay attention to the symptom.

The NAG scale can screen for hematoma expansion in acute intracerebral hemorrhage-a multi-institutional validation.

BACKGROUND: Early hematoma expansion (HE) is seen in approximately 30% of patients with intracerebral hemorrhage (ICH), but detecting patients with a high HE risk is challenging. AIMS: The NAG scale is a simple predictive scale for HE in acute ICH patients. Multi-institutional validation of the usefulness of this scale was the aim of this study. METHODS: We retrospectively reviewed 142 consecutive primary ICH patients admitted to our hospital between September 2016 and December 2018. The NAG scale consists of three factors: National Institutes of Health Stroke Scale (NIHSS) score ≥ 10, anticoagulant use, and glucose ≥133 mg/dl (1 point each). Patients underwent non-contrast computed tomography (CT) within 24 h of symptom onset and follow-up CT 6 h, 24 h, and 7 days after admission. We defined HE as increased hemorrhage volume > 33% or an absolute increase of >6 mL on follow-up CT. Poor prognosis was defined as a modified Rankin scale score of 4-6 at discharge. We performed logistic regression analysis and created receiver operating characteristic curves to determine the discrimination ability of the NAG score. RESULTS: Patients constituted 96 men and 46 women (median age: 64 years; median NIHSS: 11), and HE was observed in 38/142 patients (27%). Higher NAG sores were associated with HE (P < .001), poor prognosis (P < .001), and in-hospital death (P < .001). The C statistic was 0.72 (95% confidence interval [CI]: 0.63-0.82) for HE, 0.67 (95% CI: 0.58-0.76) for poor prognosis, and 0.85 (95% CI: 0.74-0.95) for in-hospital death. Multivariate logistic regression analysis with known risk factors showed that NAG scale score was an independent risk factor for HE (odds ratio: 2.95; 95% CI: 1.57-5.52; P = .001). CONCLUSION: The NAG scale showed good discrimination in our multi-institutional validation.

Endovascular Therapy for Concurrent Cardio-Cerebral Infarction in a Patient With Trousseau Syndrome.

Only a few patients have been reported to undergo endovascular therapy for Trousseau syndrome. This is the first report of a patient with Trousseau syndrome who developed synchronous cardiocerebral infarction and underwent endovascular therapy for both. A 55-year-old woman with Trousseau syndrome arising from stage IV ovarian cancer presented with consciousness disturbance, aphasia, and right hemiparesis. Magnetic resonance imaging showed acute cerebral infarction limited to the left basal ganglia and occlusion of the left middle cerebral artery (MCA). Electrocardiography showed ST elevation in leads II, III, and aVF with reciprocal change. Mild elevation of myocardial enzymes was observed in laboratory data. She was diagnosed with synchronous cardiocerebral infarction. Both infarctions were considered as appropriately indicated for endovascular therapy. Since her vital signs were stable, a decision was made to treat the cerebral infarction first. Thrombectomy with a stent retriever was performed, which achieved complete recanalization of the left MCA. Percutaneous coronary intervention successfully recanalized the occluded right coronary artery. She suffered no recurrence of stroke or acute coronary syndrome upon heparin administration. Cardiocerebral infarction caused by Trousseau syndrome is rare and demands optimal planning of endovascular therapy.