Comparison of efficacy between clazosentan and fasudil hydrochloride-based management of vasospasm after subarachnoid hemorrhage focusing on older and WFNS grade V patients: a single-center experience in Japan.

Subarachnoid hemorrhage often leads to poor outcomes owing to vasospasm, even after successful aneurysm treatment. Clazosentan, an endothelin receptor inhibitor, has been proven to be an effective treatment for vasospasms in a Japanese randomized controlled trial. However, its efficacy in older patients (≥ 75 years old) and those with World Federation of Neurosurgical Societies (WFNS) grade V has not been demonstrated. We retrospectively evaluated the efficacy of clazosentan in older patients and those with WFNS grade V, using real-world data. Patients with subarachnoid hemorrhage treated before and after the introduction of clazosentan were retrospectively evaluated. The patients were categorized into two groups (clazosentan era versus pre-clazosentan era), in which vasospasm management and outcomes were compared. Vasospasms were managed with fasudil hydrochloride-based (pre-clazosentan era) or clazosentan-based treatment (clazosentan era). Seventy-eight patients were included in this study: the clazosentan era (n = 32) and pre-clazosentan era (n = 46). Overall, clazosentan significantly reduced clinical vasospasms (clazosentan era: 31.3% versus pre-clazosentan era: 60.9%, p = 0.01), delayed cerebral ischemia (DCI) (9.4% versus 39.1%, p = 0.004), and vasospasm-related morbidity and mortality (M/M) (3.1% versus 19.6%, p = 0.03). In subgroup analysis of older patients or those with WFNS grade V, no significant difference was observed in clinical outcomes, although both DCI and vasospasm-related M/M were lower in the clazosentan era. Clazosentan was more effective than fasudil-based management in preventing DCI and reducing vasospasm-related M/M. Clazosentan could be used safely in older patients and those with WFNS grade V, although clinical outcomes in these patients were comparable to those of conventional treatment.

Prediction of Cross-Clamp-Induced Cerebral Ischemia During Carotid Endarterectomy Using Arterial Blood Flow Assessment.

BACKGROUND: Cross-clamping during carotid endarterectomy (CEA) is associated with the risk of cerebral ischemia. Various studies have evaluated different criteria for detecting cerebral ischemia, but difficulties arise when ischemic changes appear after the carotid artery is cross-clamped and incised. Here, we explored a parameter that can predict cerebral ischemia prior to cross-clamping during CEA using a blood-flow meter. METHODS: The carotid arterial blood flow was measured directly (direct ABF) in the common carotid artery prior to cross-clamping. The anatomical information in preoperative magnetic resonance imaging, cerebral blood flow in xenon-enhanced computed tomography, and carotid peak systolic flow velocity by carotid echo from the skin surface were also evaluated. A decrease in the short-latency somatosensory evoked potentials (SSEP) during cross-clamping to insert a shunt was assessed, and a decrease in amplitude of ≥ 50% was considered an indicator for cerebral ischemia. Surgery was performed under general anesthesia, and a shunt was inserted in all cases. RESULTS: Of 156 CEA patients between April 2013 and March 2020, 30 had decreased SSEP during cross-clamping. The baseline characteristics and intra- and postoperative findings were not significantly different between patients with and without a decrease in SSEP. Among the evaluated parameters, only the direct-ABF ratio (ABF-internal carotid artery/ABF-common carotid artery) differed significantly between the 2 groups (P = 0.011). The direct-ABF ratio ≤ 0.58 was predictive of cerebral ischemia during CEA. CONCLUSIONS: Direct-ABF measurement with an ultrasonic blood-flow meter can be useful for predicting cerebral ischemia prior to carotid artery cross-clamping during CEA.

A case of idiopathic extracranial carotid artery pseudoaneurysm with a rare clinical course and pathological features.

Extracranial carotid artery aneurysms (ECAAs) are rare, with the etiology mainly classified as degeneration or dissection. Pseudoaneurysms in the region are even rarer and are seen following trauma, iatrogenic injury, or infection. We report a case of extracranial carotid artery pseudoaneurysm (pseudo-ECAA) with a rare clinical course and pathological features. A 58-year-old man presented with swelling and purpura on the left side of his neck after sneezing. Radiological examinations suggested a ruptured left common carotid artery aneurysm. The operative findings were consistent with a pseudoaneurysm. Pathological examination revealed disarrangement and degeneration of smooth muscle fibers in the media, in addition to scattered foci of mucoid accumulation and irregular-shaped cavitation in the medial extracellular matrix, raising the possibility of an intrinsic dysfunction of the vascular wall in the pathological process of pseudoaneurysm formation.

Aspirin use and platelet aggregation in ischemic onset-type pediatric moyamoya patients with intractable headaches (moya-ache).

BACKGROUND: NSAIDs (nonsteroidal anti-inflammatory drugs) were administered to patients with ischemic onset-type moyamoya disease who experience headaches, but their therapeutic effect was very poor and resulted in a drop in quality of life (QOL). On the other hand, patients who were administered aspirin initially to prevent transient ischemic attacks (TIA) were observed to have a better QOL with the absence of headaches. Here, we report on patients with ischemic onset-type moyamoya disease experiencing headaches who received aspirin in order to verify its safety and effectiveness. METHODS: From October 2012 to July 2014, 35 patients (male: 19, female: 16 average age: 10.5 ± 3.9) with ischemic onset-type pediatric moyamoya disease and who were admitted or commuted to hospital and had surgical treatment were evaluated for background, moyamoya staging (Suzuki), presence/absence of TIA, and platelet aggregation activity by adenosine diphosphate (ADP)/collagen turbidity test. The patients were divided into four groups depending on the intensity of headache prior to being administered aspirin, and the Kruskal-Wallis test was carried out for platelet aggregation activity and moyamoya staging. Also, the 4 × 2 χ2 test was carried out for the presence/absence of TIA. Next, the items which were significant in these tests were used as independent variables to analyze the risk of headache onset, using logistic regression analysis. RESULTS: One item with statistical significance was the platelet aggregation test(PAT) value (on collagen) (P < 0.0001). A logistic regression analysis was carried out, using this value as an independent variable and headache intensity-as a dependent variable. As a result, an increase in PAT value by 1 translated into 4.43 times higher risk of the onset of intractable headache, and the onset of intractable headaches was predicted at 58.8% with collagen. The risk of developing a headache decreased as a result of aspirin administration, and the decrease was dependent on the collagen-induced aggregation suppression effect of aspirin. Aspirin was administered in the range of 1.6~9.5 mg/kg/day, and the PAT value decreasing rate was 42.9% on average. One case alone experienced nasal bleeding, and all cases showed an improvement in the intractable headaches. CONCLUSIONS: In patients with ischemic onset-type pediatric moyamoya disease who experience headaches, the platelet aggregation activity is accelerated, and aspirin administration is effective in alleviating headaches by inhibiting platelet activation, detected by the collagen PAT.

A novel omnidirectional tin-alloyed ring retractor for craniotomy in neurosurgery: technical note.

In neurosurgical operations, proper craniotomy using retractors is necessary. Various surgical instruments are used for this purpose, including standard retractors and multipurpose head frame retractor systems. However, the conventional multipurpose head frame system is often not optimal for use in some craniotomies and postures because of its size and complexity of setting. We have invented a new omnidirectional tin-alloyed (ODT) ring retractor for craniotomy with malleability and shape memory characteristics to resolve these issues. It is principally elliptical in shape, approximately 30 × 20 cm in diameter, and sufficiently firm. Accordingly, this ODT ring can retract the surgical field in all directions. Here, we report our experiences of 281 neurosurgical craniotomies using this ODT ring retractor system in various craniotomy sites and postures. Our novel ODT ring retractor is useful because of its low profile, multidirectional retractability, and less obstructiveness with its malleability. It could be used with pediatric patients where strong traction is not desirable.

Maximum Nidus Depth as a Risk Factor of Surgical Morbidity in Eloquent Brain Arteriovenous Malformations.

BACKGROUND: Eloquent location of a brain arteriovenous malformation (BAVM) is known to increase the surgical risk. Surgical removal of such BAVMs is challenging. Useful indicators for the safe removal of eloquent BAVMs are needed. The aim of this study was to determine the surgical risk factors for these challenging entities. METHODS: The authors retrospectively reviewed 29 motor and/or sensory BAVM patients who underwent surgeries. The risk factors for surgical morbidity were analyzed. As a new risk factor, maximum nidus depth, was evaluated. RESULTS: Complete obliteration was achieved in 28 patients (96.6%). Postoperative transient and permanent neurological deteriorations were seen in nine patients (31.0%) and five patients (17.2%), respectively. In univariate analysis, maximum nidus depth (p = 0.0204) and asymptomatic onset (p = 0.0229) were significantly correlated with the total morbidity. In multivariate analysis, only maximum nidus depth was significantly correlated with total morbidity (p = 0.0357; odds ratio, 2.78598; 95% confidence interval, 0.8866-8.7535). The cut-off value for the maximum nidus depth was 36 mm for total morbidity (area under the curve [AUC], 0.7428) and 41 mm for permanent morbidity (AUC, 0.8833). The cutoff value of the maximum nidus size was 30 mm for total morbidity (AUC, 0.5785) and 30 mm for permanent morbidity (AUC, 0.7625). AUC was higher for the maximum nidus depth than it was for the maximum nidus size. CONCLUSIONS: Maximum nidus depth was significantly associated with surgical morbidity of eloquent BAVMs. The maximum nidus depth is a novel and a simpler indicator of the risk of surgical morbidity.

Simmons Angled microguidewire INsertion to the Target (SAINT) technique in neuroendovascular therapy.

Advancing appropriate microcatheters is essential for treatment. However, we still encounter inaccessible arterial branches because of the anatomical arrangement. While many successful techniques regarding microcatheters have been reported, there have been very few reports of microguidewire-shaping techniques. We developed the Simmons-Angled microguidewire INsertion to the Target (SAINT) technique for insertion of the microguidewire into inaccessible arterial branches. The SAINT technique is feasible for selection and insertion into arteries that are inaccessible with conventional methods.

[A Case of Bilateral Carotid Injury Caused by Vinyl Umbrella Penetration Successfully Treated with Endovascular Therapy].

Here, we have reported a case pertaining to a 59-year-old man with bilateral traumatic carotid artery injury caused by vinyl umbrella penetration who was successfully treated. The patient fell from the stairs while holding an umbrella, which penetrated his neck. On admission, the patient was in a comatose state and the umbrella had been removed. Active bleeding was observed on the left side of the neck. Hence, tracheal intubation was performed to support respiration. Neck and head contrast-enhanced CT revealed bilateral extravasations from the carotid arteries and right middle cerebral artery(MCA)occlusion. Left carotid angiography showed extravasation from the external carotid artery(ECA), which was treated with coil embolization. Right carotid angiography revealed bleeding from the ECA and internal carotid artery(ICA)and occlusion of the MCA. The ECA and ICA were occluded by coil and n-butyl-2-cyanoacrylate embolization. After the procedures, the patient developed a large right cerebral infarction with massive brain swelling; therefore, external decompression was performed. Subsequently, the patient became alert and was able to walk with support within a month. Bilateral carotid injury is severe and difficult to treat. Endovascular therapy may be effective for the management of bilateral carotid injuries.

Prognostic Significance of Hyponatremia in Acute Stroke: A Systematic Review and Meta-Analysis.

OBJECTIVE: Hyponatremia is a common electrolyte disorder in patients with stroke, which leads to various fatal complications. We performed a systematic review and meta-analysis to investigate the outcomes of acute stroke patients with hyponatremia. METHODS: We searched MEDLINE, EMBASE, and the Cochrane Library databases for relevant literature in English published up to March 2020. Two review authors independently screened and selected the studies by assessing the eligibility and validity based on the inclusion criteria. Mortality at 90 days was set as the primary end point, and in-hospital mortality and length of hospital stay were set as the secondary end points. We conducted the data synthesis and analyzed the outcomes by calculating the odds ratio (OR) and mean difference. RESULTS: Of 835 studies, 15 studies met the inclusion criteria (n = 10,745). The prevalence rate of stroke patients with hyponatremia was 7.0-59.2%. They had significantly higher 90-day mortality (OR, 1.73; 95% confidence interval (CI), 1.24-2.42) and longer length of hospital stay (mean difference, 10.68 days; 95% CI, 7.14-14.22) than patients without hyponatremia. Patients with hyponatremia had a higher tendency of in-hospital mortality than those without hyponatremia (OR, 1.61; 95% CI, 0.97-2.69). CONCLUSIONS: The development of hyponatremia in the clinical course of stroke is associated with higher short-term mortality and a longer hospital stay. Although the causal relationship is unclear, hyponatremia could be a significant predictor of poor outcomes after stroke.

Do Direct Bypasses Really Resolve Capillary Vessels in Moyamoya Disease? Delayed Hemorrhage Potentially Relevant to Direct Bypasses: A Pathological Investigation.

OBJECTIVE: Moyamoya disease is a chronic but progressive obliterative cerebrovascular disease of bilateral internal carotid arteries (ICAs) causing hemorrhagic or ischemic cerebral strokes. Surgical revascularization has the potential for resolving the capillary vessels, but the effect on the occlusive ICA and the moyamoya vessels after a direct bypass remains unclear. PATIENT: A 2-year-old girl with a history of repeated transient ischemic attacks and direct bypasses but demonstrating improvement and associated anomaly is reported. A year and a half later, after a bilateral revascularization, an intracerebral capsulized hematoma growth was identified, and it was removed surgically. Neovascularization including many microvessels similar to capillary telangiectasia were identified by pathological investigation despite the reduction of moyamoya vessels on the repeated angiograms after the revascularization surgeries. In the present case, proliferation of capillary vessels was clearly confirmed by direct bypasses. CONCLUSION: There is no doubt that direct bypasses prevent further ischemic stroke by improving cerebral blood flow. However, they may result in failure in reducing the load of moyamoya vessels, albeit decreasing the potential risk of hemorrhagic strokes.

Can Moyamoya Disease Susceptibility Gene Affect Extracranial Systemic Artery Stenosis?

Diseases associated with the RNF213 gene include moyamoya disease, with the p.R4810K (c.14429G>A, rs112735431) homozygous variant thought to be the most pathogenic and significantly associated with severe manifestation such as early onset or cerebral infarction at onset. We report a case of a unique Japanese pedigree associated with RNF213. A 53-year-old woman with no arteriosclerotic risk factors experienced coronary artery disease, followed by coronary artery bypass surgery. In 8 years, she suffered sudden abdominal pain. Her abdominal contrast computed tomography revealed stenosis of abdominal artery and superior mesenteric artery. Though her 2 children and uncle had a typical moyamoya disease with RNF213 p.R4810K heterozygous variant, she has had no clinical and radiological evidence of moyamoya disease. Due to a family history of moyamoya disease, a genetic investigation was performed and revealed RNF213 p.R4810K homozygous variant. A possible role of RNF213 influencing systemic artery stenosis can be further be understood from this rare case harboring the homozygous variant carrier.

Genotype-Phenotype Correlation in Long-Term Cohort of Japanese Patients with Moyamoya Disease.

BACKGROUND: Homozygosity of this p.R4810K founder variant of RNF213moyamoya disease (MMD) susceptibility gene is known to influence the severity of the clinical disease phenotype at disease onset. However, the association between this genotype and long-term clinical manifestations has remained unclear. OBJECTIVES: The principal goal of this study was to investigate whether and how the p.R4810K variant of RNF213influences the long-term phenotype in Japanese patients with MMD. METHOD: This retrospective cohort study included 94 Japanese patients with MMD who underwent direct or combined bypass for revascularization with the p.R4810K genotype determined in our hospital. The following phenotypic parameters were analyzed at disease onset and over a long-term period: age and initial presentation at onset, recurrent stroke after initial revascularization, and final modified Rankin Scale. RESULTS: The p.R4810K genotype was significantly associated with the phenotype at onset, especially in younger patients. Over a median follow-up period of 100 months, recurrent stroke occurred in 6 out of 94 patients: none out of 5 patients with the homozygous variant, 5 out of 64 with the heterozygous variant, and 1 out of 25 in the wild-type group. There were no significant differences among the genotypes. In particular, recurrent cerebral hemorrhage occurred in 5 patients, all possessing the heterozygous variant. The log-rank test showed no difference between the genotypes in the stroke-free survival rate. Furthermore, the p.R4810K genotype was not associated with a poor functional condition. CONCLUSIONS: The p.R4810K founder variant of RNF213 affects the phenotype at disease onset. However, the optimal revascularization may be effective, regardless of the genotype, even for the homozygous variant, which has been thought to be the most pathogenic. This genotype may not strongly influence the long-term clinical manifestations or poor prognosis in MMD.

Usefulness of the knot-tightener device following dural suturing in endonasal transsphenoidal surgery: technical report.

Transsphenoidal surgery (TSS) has become a well-established standard surgical technique, but the cerebrospinal fluid leakage remains controversial. Direct suturing of the dura, which is a routine procedure within transcranial surgery, can be applied for closure of the sella turcica within TSS. However, as the dura is not accessible by the index finger, knot tying in the narrow and deep surgical corridor following dural suturing is extremely difficult, cumbersome, and time-consuming in TSS. Here, we present a new, simple, and effective technique for knot tying using our newly developed instrument the "knot tightener" (UC-6603: Medical U & A, Inc., Osaka, Japan) to solve this challenge. The knot tightener has a total length of 235 mm and is bayonet shaped. The tip is 5 × 10 mm in diameter and has one long arm and two short curved arms. The long arm has a dimple which can hook and hold a thread, fulfilling the role of an index finger. Together the two short curved arms make a half circle and are able to hook a thread easily. From the 28th of March 2011 to August 2018, we used the knot-tightener device for 566 patients who underwent endonasal TSS, to deliver and tie knots following stitching of the dura using 6-0 nylon. The device was able to easily deliver a knot from outside of the nostril to the sella turcica through the nasal cavity and successfully tighten it firmly. No complications were observed, confirming the safety of the newly designed instrument. The knot tightener can be considered to be an optimal tool for the challenging surgical procedure of knot tying following dural suturing in TSS. Its potential future applications may extend to include other neurosurgical procedures in anatomically restricted areas.

Efficacy of superficial temporal artery-middle cerebral artery double bypass in patients with hemorrhagic moyamoya disease: surgical effects for operated hemispheric sides.

The effects of superficial temporal artery to middle cerebral artery (STA-MCA) double bypass on recurrent hemorrhage in the operated hemisphere in hemorrhagic moyamoya disease (HMD) have not been clearly demonstrated. This study evaluated the effectiveness of STA-MCA double bypass in the prevention of further hemorrhagic or ischemic events in the operated hemispheric sides in comparison to the conservatively treated non-operated sides. We retrospectively analyzed 52 hemispheres of 36 patients with adult-onset HMD treated with STA-MCA double bypass. Twenty and 16 patients underwent unilateral (unilateral group) and bilateral (bilateral group) surgery, respectively. In addition, the perioperative and long-term outcomes of the 52 operated sides and 20 non-operated sides in the unilateral group were compared. All bypass surgeries were successful, but 21% of the operated sides showed hyperperfusion as estimated by our methods. Perioperative mortality and morbidity rate were 0% and 5.6%, respectively. Concerning long-term follow-up, the annual rebleeding rate (ARR) in the unilateral and bilateral group was 2.7% and 2.6%/person-year, respectively (p = 0.256). The ARR in the operated and non-operated sides was 1.1% and 1.8%/side-year, respectively (p = 0.163). Two of 20 non-operated sides suffered from ischemic infarction during the follow-up period, while none of the 52 operated sides experienced ischemic events (p < 0.05). Although the long-term rebleeding rate in the operated hemisphere tended to be lower after STA-MCA double bypass compared with that in the non-operated hemisphere, the difference was not statistically significant. In conclusion, while STA-MCA double bypass could not clearly prevent rebleeding, it can prevent further ischemic attacks in patients with HMD.

Correction to: Efficacy of superficial temporal artery-middle cerebral artery double bypass in patients with hemorrhagic moyamoya disease: surgical effects for operated hemispheric sides.

Table 2 of the original version of this article contained an added data. Correct Table 2 is presented here.

Clinical factors influencing the development of extracranial-intracranial bypass graft for steno-occlusive cerebrovascular disease.

OBJECTIVEEffectively retaining the patency of the extracranial-intracranial (ECIC) bypass is one of the most important factors in improving long-term results; however, the factors influencing bypass patency have not been discussed much. Therefore, the authors investigated factors influencing the development of the bypass graft.METHODSIn this retrospective study, the authors evaluated 49 consecutive hemispheres in 47 adult Japanese patients who had undergone ECIC bypass for chronic steno-occlusive cerebrovascular disease. To evaluate objectively the development of the ECIC bypass graft, the change in the area of the main trunk portion of the superficial temporal artery (STA) from before to after bypass surgery (postop/preop STA) was measured. Using the interquartile range (IQR), the authors statistically analyzed the factors associated with excellent (> 3rd quartile) and poor development (< 1st quartile) of the bypass graft.RESULTSThe postop/preop STA ranged from 1.08 to 6.13 (median 1.97, IQR 1.645-2.445). There was a significant difference in the postop/preop STA between the presence and absence of concurrent diabetes mellitus (p = 0.0432) and hyperlipidemia (0.0069). Furthermore, logistic regression analysis revealed that only concurrent diabetes mellitus was significantly associated with poor development of the bypass graft (p = 0.0235).CONCLUSIONSDiabetes mellitus and hyperlipidemia influenced the development of the ECIC bypass graft. In particular, diabetes mellitus is the only factor associated with poor development of the bypass graft.

Application of indocyanine green fluorescence endoscopic system in transsphenoidal surgery for pituitary tumors.

BACKGROUND: For the precise removal of pituitary tumors, preserving the surrounding normal structures, we need real-time intraoperative information on tumor location, margins, and surrounding structures. The aim of this study was to evaluate the benefits of a new intraoperative real-time imaging modality using indocyanine green (ICG) fluorescence through an endoscopic system during transsphenoidal surgery (TSS) for pituitary tumors. METHODS: Between August 2013 and October 2014, 20 patients with pituitary and parasellar region tumors underwent TSS using the ICG fluorescence endoscopic system. We used a peripheral vein bolus dose of 6.25 mg/injection of ICG, started with a time counter, and examined how each tissue type increased and decreased in fluorescence through time. RESULTS: A total of 33 investigations were performed for 20 patients: 9 had growth hormone secreting adenomas, 6 non-functioning pituitary adenomas, 3 Rathke's cleft cysts, 1 meningioma, and 1 pituicytoma. After the injection of ICG, the intensity of fluorescence of tumor and normal tissues under near-infrared light showed clear differences. We could differentiate tumor margins from adjacent normal tissues and define clearly the surrounding normal structures using the different fluorescent intensities time changes and tissue-specific fluorescence patterns. CONCLUSIONS: The ICG endoscopic system is simple, user-friendly, quick, cost-effective, and reliable. The method offered real-time information during TSS to delimit pituitary and parasellar region tumor tissue from surrounding normal structures. This method can contribute to the improvement of total removal rates of tumors, reduction of complications after TSS, saving surgical time, and preserving endocrinological functions.

Clinical Course and Management of Vein of Galen Varix of the Neonate: A Case Report and Literature Review.

A 28-year-old pregnant woman underwent an emergency caesarian section after 39 weeks of gestation because of decreased fetal movement and baseline fetal heart rate variability. The neonate was diagnosed with neonatal asphyxia and presented with right cardiac failure due to pulmonary hypertension. The neonate presented convulsion, and plane computed tomography (CT) showed dilation of the vein of Galen and sinuses on day 3. Magnetic resonance imaging and CT with contrast were performed after cardiac failure subsided, and there was no evidence of arteriovenous shunt and normalization of the vein of Galen. The patient was diagnosed with vein of Galen varix (VGV). In the previous literature, only 3 cases of VGV have been reported. VGV is considered to be caused by right cardiac failure without the presence of an arteriovenous shunt and requires treatment only for cardiac failure and its cause. Therefore, it is important to differentiate VGV from vein of Galen aneurysmal malformation.

Risk Factors for Acute Heart Failure and Impact on In-Hospital Mortality after Stroke.

BACKGROUND: In the acute phase of stroke, some patients develop cardiac events. It could be fatal in their clinical courses. We aimed to investigate acute heart failure after stroke onset and stratify the patients by establishing a predictive model. METHODS: This single-center, observational study included stroke patients diagnosed at the Department of Neurology and Neurosurgery from January 2013 to December 2014. Baseline characteristics and clinical findings on admission were analyzed for acute heart failure after stroke. We assessed risk factors using multivariable logistic regression, and set a risk score to evaluate the association with poor outcomes. RESULTS: Of 532 stroke patients, 27 (5%) developed acute heart failure within the 7 days after admission. We identified 4 risk factors for acute heart failure after stroke: atrial fibrillation (odds ratio [OR], 5.9; 95% confidence interval [CI], 2.5-14.0; P < .001), history of cardiac disease (OR, 3.6; 95% CI, 1.3-9.1; P = .01), Glasgow Coma Scale score ≤ 8 (OR, 4.5; 95% CI, 1.7-12.0; P = .003), and serum albumin < 35 g/L (OR, 3.4; 95% CI, 1.4-8.4; P = .008). Furthermore in-hospital mortality rate was higher (37% [n = 10/27] versus 9.9% [n = 50/505], P = .001) in patients with poststroke heart failure. Higher predictive scores were associated with increased mortality. CONCLUSIONS: Acute heart failure can develop in the early phase of stroke and lead to poor outcomes. It is foreseeable and preventable by stratifying and monitoring high-risk patients.

[Supratentorial Meningeal Melanoma with Nevus of Ota:A Case Report].

We present a rare case of supratentorial meningeal melanoma associated with ipsilateral nevus of Ota, and a review of the literature. The patient was a 32-year-old man with a right-sided nevus of Ota, presenting with unconsciousness. His CT and MRI scans revealed an extra axial tumor with dural tail signs; no lesion was detected on systemic examination. Intraoperatively, the tumor demonstrated black hyperpigmentation and was histologically diagnosed as malignant melanoma. Following surgery, he received radiotherapy and chemotherapy. For over a year and a half, the patient has shown no recurrence of the lesion.