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The first postmortem neuropathological findings of a hemiparkinsonism and hemiatrophy (HPHA) patient are presented. A 50-year-old man developed resting tremors affecting the right hand and leg, followed by mild clumsiness of the right hand. On examination, he exhibited muscle atrophy of the right leg extremity, accompanied by right-sided parkinsonism. Brain magnetic resonance imaging was normal. Based on the clinical and radiological findings, HPHA syndrome was diagnosed, showing a good response to L-DOPA. He gradually developed muscular atrophy of the right distal upper extremity. Thirteen years after the onset of the disease, left-sided parkinsonism appeared. The patient died of Trousseau's syndrome associated with a rapidly emerging pancreatic tumor. The total duration of the disease was 14 years. Neuropathologically, the substantia nigra showed markedly left-predominant neuronal loss, along with almost symmetrical Lewy body (LB) pathology. These findings indicated that the patient originally had fewer neurons in the left substantia nigra than in the right, probably caused by congenital or childhood cerebral injury, followed by the development of unilateral parkinsonism due to the progression of LB pathology. Despite our extensive neuropathological analysis, we could not specify the etiology or anatomical substrate responsible for the development of right upper and lower extremity atrophy. Further clinicopathological studies are needed to elucidate the pathoanatomical areas causing hemiparkinsonism and hemiatrophy.
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OBJECTIVES: Falls can occur daily in stroke patients and appropriate independence assessments for fall prevention are required. Although previous studies evaluated the short physical performance battery (SPPB) in stroke patients, the relationship between SPPB and fall prediction and walking independence remains unclear. Therefore, we aimed to verify whether SPPB is a predictor of walking independence. MATERIALS AND METHODS: The present study included 105 hemiplegic stroke patients who were admitted to the rehabilitation ward and gave consent to participate. Cross-sectional physical function and functional independence measure cognitive (FIM-C) evaluation were conducted in hemiplegic stroke patients. Logistic regression analysis using the increasing variable method (likelihood ratio) was performed to extract factors for walking independence. Cutoff values were calculated for the extracted items using the receiver operating-characteristic (ROC) curve. RESULTS: Among 86 participants included in the final analysis, 36 were independent walkers and 50 were dependent walkers. In the logistic regression analysis, SPPB and FIM-C were extracted as factors for walking independence. The cutoff value was 7 [area under the curve (AUC), 0.94; sensitivity, 0.83; specificity, 0.73)] for SPPB and 32 (AUC, 0.83; sensitivity, 0.69; specificity, 0.57) for FIM-C in ROC analysis CONCLUSIONS: SPPB and FIM-C were extracted as factors for walking independence. Although SPPB alone cannot determine independent walking, combined assessment of SPPB with cognitive function may enable more accurate determination of walking independence.
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Rehabilitación de Accidente Cerebrovascular , Accidente Cerebrovascular , Estudios Transversales , Marcha , Hemiplejía/diagnóstico , Hemiplejía/etiología , Humanos , Rendimiento Físico Funcional , Accidente Cerebrovascular/complicaciones , Accidente Cerebrovascular/diagnósticoRESUMEN
Curative endovascular treatment of sphenoid wing dural arteriovenous fistula (dAVF) with pure cortical venous drainage is challenging because of its rarity, lack of accessible dural sinus for transvenous embolization (TVE), and proximity of skull base vital regions. Direct surgery to disconnect venous reflux has been favored. We report the curative endovascular treatment of two sphenoid wing dAVFs with pure cortical venous drainage. One patient revealed complete obliteration of dAVF by a single session of transarterial embolization (TAE). As part of strategic TAE for this complex dAVF, we used a novel approach to create a complete flow-arrest condition in which coils and an occlusion balloon were combined. A liquid agent was then injected across the pathological fistula and into the parent venous apparatus, thereby occluding the lesion. The other patient was treated with percutaneous TVE after TAE was unsuccessful. With a specific strategy and appropriate devices, the microcatheter was successfully introduced through sigmoid sinus, transverse sinus, superior sagittal sinus, and refluxing cortical vein by puncture of the jugular vein. Coils were deployed at the venous side of the fistula, resulting in successful obliteration of the dAVF. Sphenoid wing dAVF with pure cortical venous drainage could be curable by endovascular treatment with proper strategy and instruments when anatomical condition permits.
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Malformaciones Vasculares del Sistema Nervioso Central/cirugía , Senos Craneales/cirugía , Procedimientos Endovasculares , Procedimientos Neuroquirúrgicos/métodos , Adulto , Humanos , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
A 47-year-old man was admitted to our hospital because of sudden-onset motor aphasia and right hemiplegia. His past medical history was notable for left craniotomy and hematoma evacuation following a traumatic brain hemorrhage approximately 40 years earlier, for which dural grafting was performed. He also had a history of three lobar hemorrhages in the left hemisphere since the age of 42 years. Brain CT imaging revealed an acute left frontal lobar hemorrhage. His initial brain MRI conducted at our hospital demonstrated hemorrhagic findings with left hemisphere dominance, including acute and old lobar hemorrhage, cortical superficial siderosis, and cerebral microbleeds. Cerebrospinal fluid analyses demonstrated reduced levels of cerebral amyloid-ß 42, and elevated total tau. His apolipoprotein E genotype was ε3/ε3. Whole-exome sequencing did not detect mutations in genes associated with Alzheimer's disease, including presenilin 1, presenilin 2, and amyloid precursor protein. These findings led to a clinical diagnosis of iatrogenic cerebral amyloid angiopathy (CAA) using recently proposed diagnostic criteria, which do not require pathological evaluation of the brain. Iatrogenic CAA should be considered as a cause of lobar hemorrhage in young patients, especially those with a past history of neurosurgery.
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BACKGROUND: Non-cardioembolic ischemic stroke (NCIS) and ischemic heart disease (IHD) require secondary prevention with antiplatelet therapy (APT). We investigated APT prescription status for patients with NCIS and IHD. RESEARCH DESIGN AND METHODS: This retrospective study utilized claims data from patients with NCIS and those who underwent percutaneous coronary intervention for IHD and received antiplatelet drugs. The study included Phases A (2015-2016), B (2017-2018), and C (2019-2020). We evaluated patient characteristics, APT prescription rates (dual [DAPT] and single [SAPT]), and prescriptions by NCIS subtype. RESULTS: In the NCIS cohort, the initial DAPT prescription rate increased over time (Phase A: 14.9%, B: 19.2%, C: 28.0%), but decreased to 6% after 3 months. Subsequently, 25% of patients did not receive APT. For IHD, DAPT duration decreased over time, with 12-month prescription rates of 48.0%, 43.1%, and 32.6% for Phases A, B, and C, respectively. SAPT prescriptions, predominantly aspirin, increased, and use of P2Y12 inhibitors also rose. Few patients (10%) did not receive APT. CONCLUSIONS: Shorter DAPT duration/earlier switching to SAPT for NCIS and IHD have gained acceptance in regional medical care. A higher proportion of NCIS vs IHD patients did not receive APT in the chronic phase. TRIAL REGISTRATION: UMIN000052198.
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Accidente Cerebrovascular Isquémico , Inhibidores de Agregación Plaquetaria , Humanos , Inhibidores de Agregación Plaquetaria/uso terapéutico , Inhibidores de Agregación Plaquetaria/administración & dosificación , Estudios Retrospectivos , Masculino , Femenino , Anciano , Japón , Persona de Mediana Edad , Accidente Cerebrovascular Isquémico/tratamiento farmacológico , Isquemia Miocárdica/tratamiento farmacológico , Prevención Secundaria/métodos , Intervención Coronaria Percutánea , Pautas de la Práctica en Medicina/estadística & datos numéricos , Pautas de la Práctica en Medicina/tendencias , Anciano de 80 o más Años , Revisión de Utilización de Seguros , Estudios de Cohortes , Factores de Tiempo , Terapia Antiplaquetaria Doble , Trastornos Cerebrovasculares/tratamiento farmacológico , AdultoRESUMEN
BACKGROUND: Delirium is considered to worsen life prognosis in elderly patients with stroke. We examined the effects of the melatonin receptor agonist ramelteon for treating delirium in elderly stroke patients with insomnia in comparison to the other drugs. METHODS: Elderly patients with delirium and insomnia after acute stroke who were treated with ramelteon (7 patients; mean age 76 years) and the other drugs (21 patients; mean age 77.3 years) between July 2011 and March 2012 at our hospital were retrospectively examined. RESULTS: All patients treated with ramelteon had a significant improvement within a week and were started on early and aggressive rehabilitation. No patient experienced oversedation, neurologic deterioration, or any other worsening effect associated with ramelteon treatment. CONCLUSIONS: Melatonin receptor agonists may be effective for the treatment of delirium in elderly patients with acute stroke.
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Delirio/tratamiento farmacológico , Indenos/uso terapéutico , Receptores de Melatonina/agonistas , Accidente Cerebrovascular/complicaciones , Anciano , Anciano de 80 o más Años , Delirio/complicaciones , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Resultado del TratamientoRESUMEN
BACKGROUND: In endovascular embolization of intracranial aneurysms, a tortuous cervical internal carotid artery can limit guiding catheter access to a sufficiently high position. Although intermediate distal access catheters can go beyond the tortuous segment of internal carotid arteries, they may increase the risk of procedure-related complications, require significantly complex technical procedures, and limit the use of adjunctive techniques. Using simple neck extension alone, we successfully improved guiding catheter access in 2 patients. METHODS: Through a provocative test, we confirmed suitability of manual neck extension in 2 patients with severe posterior curvature of a tortuous internal carotid artery. Intraoperatively, we manually extended the neck and stretched the curvatures. We guided a 6F guiding catheter superiorly and performed coil embolization with an occlusion balloon catheter in 1 case and with the balloon-assisted neck remodeling technique in 1 case. RESULTS: Coil embolization was completed without any adverse events in both cases. CONCLUSIONS: The simple neck extension technique successfully improved accessibility of the guiding catheter. As the need for safe and highly skilled intervention increases, our technique may be useful because it can reduce procedure-related complications and allow balloon-assisted techniques.
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Arteria Carótida Interna/cirugía , Cateterismo/métodos , Embolización Terapéutica/métodos , Procedimientos Endovasculares/métodos , Aneurisma Intracraneal/cirugía , Instrumentos Quirúrgicos/estadística & datos numéricos , Anciano , Arteria Carótida Interna/diagnóstico por imagen , Cateterismo/instrumentación , Embolización Terapéutica/instrumentación , Procedimientos Endovasculares/instrumentación , Femenino , Humanos , Aneurisma Intracraneal/diagnóstico por imagen , Persona de Mediana Edad , Cuello/diagnóstico por imagen , Cuello/cirugíaRESUMEN
Objective To assess the correlation between the angiographic appearance of cerebral collateral pathways or the degree of internal carotid artery stenosis (ICAS) and reduced cerebrovascular reactivity (CVR) estimated by single-photon emission computed tomography (SPECT) image analysis in patients with unilateral ICAS. Methods A retrospective analysis was performed in 42 patients with unilateral ICAS who underwent cerebral angiography and acetazolamide-challenged SPECT of the brain. Cerebral blood flow quantitation was performed using the quantitative SPECT/dual-table autoradiography method. The CVR in the middle cerebral artery (MCA) territory was evaluated using the stereotactic extraction estimation based on the Japanese extracranial-intracranial bypass trial (SEE-JET) program and classified as reduced (<18.4%) or non-reduced (≥18.4%). Angiographic collateralization was classified as circle of Willis (type 1), extracranial-intracranial (type 2), and leptomeningeal (type 3). The degree of ICAS was defined as severe (≥70% stenosis) or non-severe (<70%). Results Eight patients showed reduced CVR, including 6 (46%) of 13 with type 3 collaterals and 2 (7%) of 29 without type 3 collaterals (p=0.006). In contrast, type 1 and type 2 collaterals and severe ICAS were not significantly associated with reduced CVR. Conclusion In patients with unilateral ICAS, leptomeningeal collaterals are strongly correlated with reduced CVR in the MCA territory, which presumably increases the risk of cerebral hyperperfusion after carotid artery stenting (CAS). Therefore, these findings may be clinically applicable to the perioperative management of CAS.
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Encéfalo/diagnóstico por imagen , Estenosis Carotídea/diagnóstico por imagen , Arteria Cerebral Media/diagnóstico por imagen , Tomografía Computarizada de Emisión de Fotón Único/métodos , Acetazolamida/farmacocinética , Anciano , Anciano de 80 o más Años , Encéfalo/patología , Estenosis Carotídea/patología , Angiografía Cerebral , Circulación Cerebrovascular/fisiología , Constricción Patológica , Femenino , Humanos , Imagenología Tridimensional , Masculino , Persona de Mediana Edad , Arteria Cerebral Media/patología , Estudios RetrospectivosRESUMEN
Background@#and Purpose Recent studies suggested an increased incidence of cerebral venous thrombosis (CVT) during the coronavirus disease 2019 (COVID-19) pandemic. We evaluated the volume of CVT hospitalization and in-hospital mortality during the 1st year of the COVID-19 pandemic compared to the preceding year. @*Methods@#We conducted a cross-sectional retrospective study of 171 stroke centers from 49 countries. We recorded COVID-19 admission volumes, CVT hospitalization, and CVT in-hospital mortality from January 1, 2019, to May 31, 2021. CVT diagnoses were identified by International Classification of Disease-10 (ICD-10) codes or stroke databases. We additionally sought to compare the same metrics in the first 5 months of 2021 compared to the corresponding months in 2019 and 2020 (ClinicalTrials.gov Identifier: NCT04934020). @*Results@#There were 2,313 CVT admissions across the 1-year pre-pandemic (2019) and pandemic year (2020); no differences in CVT volume or CVT mortality were observed. During the first 5 months of 2021, there was an increase in CVT volumes compared to 2019 (27.5%; 95% confidence interval [CI], 24.2 to 32.0; P<0.0001) and 2020 (41.4%; 95% CI, 37.0 to 46.0; P<0.0001). A COVID-19 diagnosis was present in 7.6% (132/1,738) of CVT hospitalizations. CVT was present in 0.04% (103/292,080) of COVID-19 hospitalizations. During the first pandemic year, CVT mortality was higher in patients who were COVID positive compared to COVID negative patients (8/53 [15.0%] vs. 41/910 [4.5%], P=0.004). There was an increase in CVT mortality during the first 5 months of pandemic years 2020 and 2021 compared to the first 5 months of the pre-pandemic year 2019 (2019 vs. 2020: 2.26% vs. 4.74%, P=0.05; 2019 vs. 2021: 2.26% vs. 4.99%, P=0.03). In the first 5 months of 2021, there were 26 cases of vaccine-induced immune thrombotic thrombocytopenia (VITT), resulting in six deaths. @*Conclusions@#During the 1st year of the COVID-19 pandemic, CVT hospitalization volume and CVT in-hospital mortality did not change compared to the prior year. COVID-19 diagnosis was associated with higher CVT in-hospital mortality. During the first 5 months of 2021, there was an increase in CVT hospitalization volume and increase in CVT-related mortality, partially attributable to VITT.