A novel NODAL variant in a young embolic stroke patient with visceral heterotaxy.

BACKGROUND: Ischemic stroke in young adults can be caused by a variety of etiologies including the monogenic disorders. Visceral heterotaxy is a condition caused by abnormal left-right determinations during embryonic development. We aimed to determine the cause of a young ischemic stroke patient with visceral heterotaxy. CASE PRESENTATION: We performed neurological, radiological, and genetic evaluations in a 17-year-old male patient presenting ischemic stroke and visceral heterotaxy to determine the underlying cause of this rare disease combination. Brain magnetic resonance imaging (MRI) showed evidence of embolic stroke, abdominal computed tomography (CT) showed visceral heterotaxy, and echocardiogram showed cardiac anomaly with right-to-left-shunt (RLS). Whole genome sequencing (WGS) revealed a heterozygous missense variant (NM_018055.5: c.1016 T > C, p.(Met339Val)) in the NODAL gene, which is essential to the determination of the left-right body axis. CONCLUSIONS: Our study highlights the importance of evaluating genetic etiology in young ischemic stroke and the need for stroke risk management in visceral heterotaxy patients with RLS. To the best of our knowledge, we report the first genetically-confirmed case of visceral heterotaxy with young embolic stroke reported to date.

[Neurological Complications Associated with Kidney Disease].

The kidneys filter the blood to excrete waste products and excess salt from the body as urine, while reabsorbing what the body needs and keeping it in the body. For this reason, when the function of the kidneys deteriorates, urine cannot be produced, and homeostasis of electrolytes and acid-bases cannot be maintained. As a result, waste products accumulate in the body, resulting in uremia and the need for dialysis induction or kidney transplant. This paper provides an overview of the neurological complications that appear in kidney disease and their treatment.

[Varicella-Zoster Myelitis with Medullary Infarction: A Case Report].

We present the case of a 62-year-old woman who was receiving treatment for herpes zoster and experienced paraplegia, and bladder and bowel disturbance. The brain MRI diffusion-weighted image showed an abnormal hyperintense signal and apparent diffusion coefficient decreased in left medulla oblongata. The spinal cord MRI T2-weighted image showed abnormal hyperintense lesions in the left side of cervical spinal cord and thoracic spinal cord. We diagnosed varicella-zoster myelitis with medullary infarction, because varicella-zoster virus DNA was detected in the cerebrospinal fluid by polymerase chain reaction. The patient recovered with early treatment. This case shows the importance of evaluating not only skin lesions, but also distant lesions. (Received 15 November, 2022; Accepted 12 Jaunuary, 2023; Published 1 March, 2023).

Usefulness of carotid duplex ultrasonography in predicting residual large-vessel occlusions after intravenous recombinant tissue plasminogen activator therapy in patients with acute ischemic stroke.

PURPOSE: Endovascular therapy (EVT) preceded by intravenous thrombolysis with recombinant tissue plasminogen activator (iv-rtPA) has been established as a standard treatment in patients with stroke caused by large-vessel occlusion (LVO). Primary stroke centers without EVT competence need to identify patients with residual LVO after iv-rtPA therapy and transport them to an EVT-capable facility. Carotid ultrasonography (CUS) is easily applicable at bed side and useful for detecting extra- and intracranial LVO. This study aimed to determine whether CUS findings at admission are useful to predict patients with residual LVO after iv-rtPA. METHODS: Patients scheduled to undergo iv-rtPA for acute cerebral infarction were registered. Before iv-rtPA, they underwent CUS, followed by CTA or MRA evaluation within 6 h after iv-rtPA. A model that can achieve 100% sensitivity for detecting residual LVO after iv-rtPA was studied. RESULTS: This study included 68 of 116 patients treated with iv-rtPA during the study period. National Institutes of Health Stroke Scale (NIHSS) score (cutoff value = 10) on arrival, hyperdense MCA sign on non-contrast CT, end-diastolic (ED) ratio on CUS, and eye deviation were significantly different between patients with residual LVO after iv-rtPA and those without. If any of these clinical features are positive in the screening test, residual LVO could be predicted with 100% sensitivity, 50% specificity, 64% positive predictive value, and 100% negative predictive value. CONCLUSION: Prediction of residual LVO with 100% sensitivity may be feasible by adding CUS to NIHSS score > 10, the presence of eye deviation, and hyperdense MCA sign.

The Utility of Automated ASPECTS in Acute Ischemic Stroke for Intravenous Recombinant Tissue Plasminogen Activator (IV-rtPA) Therapy.

PURPOSE: This study aimed to investigate the accuracy and clinical significance of an artificial intelligence (AI)-based automated Alberta Stroke Program Early Computed Tomography (ASPECT) scoring software of head CT for the indication of intravenous recombinant tissue plasminogen activator (rt-PA) therapy. METHODS: This study included two populations of acute ischemic stroke: one comprised patients who had undergone head CT within 48 h of presentation (Population #1, n = 448), while the other included patients within 4.5 h from onset (Population #2, n = 132). The primary endpoint was the concordance rate of ASPECTS of the neurologists and AI software against the benchmark score. The secondary endpoints were to validate the accuracy of the neurologist and AI software in assessing the ability to rule out extensive infarction (ASPECTS of 0-5) in population #2. RESULTS: The reading accuracy of AI software was comparable to that of the board-certified vascular neurologists. The detection rate of cardiogenic cerebral embolism was better than that of atherothrombotic cerebral infarction. By excluding extensive infarction, AI-software showed a higher specificity and equivalent sensitivity compared to those of experts. CONCLUSIONS: The AI software for ASPECTS showed convincing agreement with expert evaluation and would be supportive in determining the indications of intravenous rt-PA therapy.

Prediction of recurrent stroke among ischemic stroke patients with atrial fibrillation: Development and validation of a risk score model.

BACKGROUND: There is currently no validated risk prediction model for recurrent events among patients with acute ischemic stroke (AIS) and atrial fibrillation (AF). Considering that the application of conventional risk scores has contextual limitations, new strategies are needed to develop such a model. Here, we set out to develop and validate a comprehensive risk prediction model for stroke recurrence in AIS patients with AF. METHODS: AIS patients with AF were collected from multicenter registries in South Korea and Japan. A developmental dataset was constructed with 5648 registered cases from both countries for the period 2011‒2014. An external validation dataset was also created, consisting of Korean AIS subjects with AF registered between 2015 and 2018. Event outcomes were collected during 1 year after the index stroke. A multivariable prediction model was developed using the Fine-Gray subdistribution hazard model with non-stroke mortality as a competing risk. The model incorporated 21 clinical variables and was further validated, calibrated, and revised using the external validation dataset. RESULTS: The developmental dataset consisted of 4483 Korean and 1165 Japanese patients (mean age, 74.3 ± 10.2 years; male 53%); 338 patients (6%) had recurrent stroke and 903 (16%) died. The clinical profiles of the external validation set (n = 3668) were comparable to those of the developmental dataset. The c-statistics of the final model was 0.68 (95% confidence interval, 0.66 ‒0.71). The developed prediction model did not show better discriminative ability for predicting stroke recurrence than the conventional risk prediction tools (CHADS2, CHA2DS2-VASc, and ATRIA). CONCLUSIONS: Neither conventional risk stratification tools nor our newly developed comprehensive prediction model using available clinical factors seemed to be suitable for identifying patients at high risk of recurrent ischemic stroke among AIS patients with AF in this modern direct oral anticoagulant era. Detailed individual information, including imaging, may be warranted to build a more robust and precise risk prediction model for stroke survivors with AF.

Utility of transoral motion-mode ultrasonography to detect tongue fasciculation in patients with amyotrophic lateral sclerosis.

INTRODUCTION: Increasing evidence suggests the utility of the submandibular approach for ultrasonography to detect tongue fasciculation in amyotrophic lateral sclerosis (ALS). We hypothesized that transoral motion-mode ultrasonography (TOMU) would be useful to detect tongue fasciculation in patients with ALS. METHODS: Patients with sporadic ALS showing clinically definite tongue fasciculation were enrolled, and the ultrasonography findings of patients' tongues on TOMU and ultrasonography by the conventional submandibular approach were analyzed. RESULTS: Six patients with clinically definite ALS were enrolled in this study. Although small, irregular muscle movements of 5 to 10 mm in amplitude and 0.1 to 0.2 second in duration were detected in all patients by TOMU, similar muscle movements were detected in only two of the six patients by the submandibular approach. DISCUSSION: TOMU appeared to be useful for detecting tongue fasciculation in ALS patients. Further study is needed to better determine its role as a diagnostic tool for ALS.

Soleal vein dilatation in the early phase of hospitalization is associated with subsequent development of deep vein thrombosis in patients with acute stroke.

PURPOSE: To evaluate the usefulness of soleal vein (SOV) diameter as a predictor of new onset of deep vein thrombosis (DVT) in acute stroke patients. METHODS: A total of 121 acute stroke patients who were admitted within 48 h of onset underwent a calf vein ultrasonography (CVUS) examination within 7 days after hospitalization. They were evaluated for the presence of DVT and risk factors including maximum SOV diameter. Next, the patients in whom DVT was not detected at the first CVUS examination underwent a second CVUS examination on the 21st hospital day, and were evaluated for the presence of new DVT. RESULTS: DVT was detected in 27 of 121 patients at the first CVUS examination. A significant association was noted between the presence of DVT and higher levels of soluble fibrin monomer, D-dimer, and C-reactive protein, and a higher rate of having cancer concomitantly. Furthermore, 50 of 94 patients without DVT at the first CVUS examination underwent a second CVUS examination. Of the 94 patients, 44 were excluded, because they were discharged by the 21st day. Note that DVT was newly developed in 12 of the 50 patients who underwent the second CVUS. A significant association was found between the presence of new DVT and the rate of history of stroke, hematocrit level, and maximum SOV diameter at the first examination. CONCLUSION: In our acute stroke patients, SOV dilation, history of stroke, and elevated hematocrit level were found to be associated with risk of developing a new DVT.

Leber's hereditary optic neuropathy with diffuse white matter changes mimicking gliomatosis cerebri: illustrative case.

BACKGROUIND: Leber's hereditary optic neuropathy (LHON) is a mitochondrial disease characterized by bilateral severe subacute central vision loss and a mutation in the mitochondrial DNA (mtDNA). The findings on cranial magnetic resonance imaging of patients with LHON vary from subtle to multiple white matter changes. However, they rarely present with diffuse infiltrative white matter changes. OBSERVATIONS: The authors reported a case with diffuse white matter changes mimicking gliomatosis cerebri (GC). The histological findings included only mild glial hyperplasia without immunohistochemical positivity, supporting the diagnosis of glial tumors. Analysis of mtDNA obtained from the blood and brain tissue revealed mutation of m.11778G>A in the NADH dehydrogenase 4 gene, which confirmed the case as LHON. Immunohistochemistry of the brain tissue revealed 8-hydroxy-2'-deoxyguanosine positivity, suggesting the presence of oxidative stress. LESSONS: LHON is extremely difficult to diagnose unless one suspects or knows the disease. The present case brings attention not only to LHON but also to other mtDNA-mutated diseases that need to be considered with diffuse white matter changes or GC.

The Risk Factors for Death within 6 Months After Ischemic Stroke in Patients with Cancer.

OBJECTIVES: While the intravenous recombinant tissue plasminogen activator (rt-PA) therapy for acute ischemic stroke patients with cancer is recommended when survival of ≥ 6 months is expected, the risk factors for death and stroke recurrence within 6 months after stroke are not well known. Thus, we aimed to identify markers for death and recurrence risks within six months from stroke onset in patients with cancer. MATERIALS AND METHODS: In a retrospective cohort study, the subjects comprised acute ischemic stroke patients with cancer hospitalized at St. Marianna University hospital from 2008 through 2019. To evaluate the associations between the clinical factors within 24 h of the initial stroke and death or stroke recurrence events within 6 months from stroke onset, Logistic analysis and Cox proportional hazards regression analysis was used respectively. Next, the optimal cutoff point of markers for different mortality groups was determined using the receiver operating characteristic curve analysis and cumulative outcome rate of each group was compared using the Kaplan-Meier method. RESULTS: Among 194 patients with cancer who developed acute stroke, 167 were ultimately selected for analysis. 47 subjects (28.14%) passed away within 6 months following stroke onset, and 20 subjects (11.98%) had stroke recurrence. High D-dimer levels, low fibrinogen levels, high Glasgow prognostic scores (GPS), and multiple vascular territory infarctions was independently associated with death, where higher death rate was significantly confirmed in the group with D-dimer levels of ≥3.95 mg/dl, fibrinogen levels <277.5 mg/dl and GPS scores of 2. Low fibrinogen level, lack of antithrombotic therapy, and the presence of metastasis were associated with stroke recurrence. CONCLUSIONS: When patients with cancer suffer stroke, D-dimer levels, fibrinogen levels, GPS, and multiple vascular territory infarctions would be associated with the risk of death within 6 months. Low fibrinogen levels, lack of antithrombotic therapy, and the presence of metastasis correlated with high risk of stroke recurrence.

The ASCOD Phenotyping of Embolic Strokes of Undetermined Source.

BACKGROUND AND PURPOSE: Various pathogenesis are presumed to be involved in the etiology of embolic stroke of undetermined source (ESUS), which has a high recurrence rate, and much remains unknown about the clinical subtype of recurrent stroke. The purpose of this study was to clarify the pathogenesis of ESUS using the ASCOD classification for ESUS patients and to examine the factors involved in the recurrence of ischemic stroke. METHODS: The subjects of this study were 236 of these patients who fulfilled the criteria for ESUS. The rate of stroke recurrent, subtype of recurrent ischemic stroke, and new-onset atrial fibrillation (AF) in these patients were surveyed retrospectively, and each patient was graded for the A, S, and C categories of the ASCOD classification. RESULTS: Ischemic stroke recurred in 32 patients during the follow-up period (7 days to 12.9 years [median 54.3 months]), and new-onset AF was seen in 44 (18.6%) patients. The most subtype of recurrent ischemic stroke was ESUS again (19 patients). Multivariate analysis with a Cox proportional hazards model, the S score (hazard ratio 5.21; 95% confidence interval (CI) 2.38-11.42; P < .001) and the number of A, S, C categories (hazard ratio 1.90; 95% CI 1.14-3.10; P = .013) were factors significantly related to recurrent ischemic stroke. CONCLUSIONS: Assessment of comorbid conditions in ESUS patients based on the ASCOD classification may be useful in predicting the likelihood of recurrence of ischemic stroke.

Barriers to continued administration of direct oral anticoagulants between acute hospital and subacute or chronic hospitals and geriatric health services facilities in Japan.

Objectives: To investigate whether direct oral anticoagulant (DOAC) therapy at acute hospitals is continued after transfer to subacute or chronic hospitals and geriatric health services facilities in Japan.Methods: Acute hospitals routinely transfer patients to nearby subacute or chronic hospitals and geriatric health services facilities after acute stroke treatment. To elucidate the status of antithrombotic therapy, particularly DOAC therapy, we conducted a questionnaire survey of chief physicians at 33 subacute or chronic hospitals and geriatric health services facilities in the vicinity of Kawasaki City.Results: Responses were received from 23 hospitals and geriatric health services facilities (5 convalescent and rehabilitation hospitals, 5 chronic hospitals, 13 geriatric health services facilities). The number of convalescent hospitals responding, 'no problem with DOAC administration' before transfer to subacute or chronic hospitals and geriatric health services facilities increased from 4 (80%) at the introduction of DOACs to 5 (100%) presently. The number of chronic hospitals and geriatric health services facilities also increased from 1 (20%) to 3 (60%) and 4 (30.8%) to 5 (38.5%), respectively, albeit not significantly. The number of convalescent hospitals, chronic hospitals, and geriatric health services facilities requesting pre-transfer change of oral anticoagulants decreased from 20% to 0%, 60% to 40%, and 69.2% to 61.5%, respectively. All convalescent hospitals continued DOAC therapy after transfer. However, only 40.0% of chronic hospitals and 46.2% of geriatric health services facilities used DOACs in the present period. Warfarin was used instead at 3 (60%) chronic hospitals and 7 (53.8%) geriatric health services facilities and antiplatelet drugs were used at 1 hospital/facility each (20% and 7.7%, respectively). Nine (39.1%) hospitals and facilities cited high DOAC costs for the switch.Conclusions: Convalescent hospitals have incorporated DOAC use and readily accept patients receiving DOACs at transferring hospitals. Conversely, many chronic hospitals and geriatric health services facilities eventually switch from DOACs to warfarin or antiplatelet drugs due to cost. Efforts to resolve these barriers to continued administration of DOACs between acute hospitals and subacute or chronic hospitals and geriatric health services facilities in Japan are needed as soon as possible.

Effectiveness of the traditional Japanese Kampo medicine Yokukansan for chronic migraine: A case report.

RATIONALE: The traditional Japanese Kampo medicine Yokukansan (TSUMURA Yokukansan extract granules) was originally used to treat neurosis, insomnia, night crying, and irritability and/or agitation in infants and recently it has also been used for neuropsychiatric symptoms in Alzheimer's disease or other dementia in Japan. Furthermore, several recent studies have reported the efficacy of Kampo medicines for various types of headache. Here, we report a case of severe chronic migraine refractory to prophylactic therapy using various western medicines and Japanese Kampo medicines that had resulted in a leave of absence from work, but for which the frequency and severity were markedly decreased by Yokukansan (2.5 g 3 times/d), enabling the patient to return to work fully. PATIENT CONCERNS: The patient was a 39-year-old woman with a diagnosis of migraine without aura, which started around the age of 17 years and had been well managed with oral triptan preparations. However, due to lifestyle changes after childbirth, the frequency and severity of migraine increased at 38 years of age, prompting her to visit our hospital. DIAGNOSES: Our initial examination found no neurological abnormality, and our diagnosis was also migraine without aura based on the International Classification of Headache Disorders version 3. INTERVENTIONS: Her migraine had become refractory to several western medicines (lomerizine hydrochloride, propranolol, sodium valproate, amitriptyline, and duloxetine) and 2 Japanese Kampo medicines (Goshuyuto and Chotosan). The migraine episodes worsened, and consequently she took a leave of absence from work. OUTCOMES: Yokukansan was then tried, and this markedly improved the chronic migraine, enabling her full return to work. LESSONS: Yokukansan might have exerted a prophylactic effect on chronic migraine via its action on the glutamatergic and serotonergic systems, inhibitory action on orexin A secretion, and anti-inflammatory action. Yokukansan might be useful as a prophylactic for migraine worldwide, and a future large-scale clinical study is warranted.

Risk of Hyperglycemia and Hypoglycemia in Patients with Acute Ischemic Stroke Based on Continuous Glucose Monitoring.

BACKGROUND: In patients with acute ischemic stroke, current guidelines recommend maintaining blood glucose levels in a range of 140-180 mg/dL and closely monitoring to prevent hypoglycemia (<60 mg/dL). We aimed to assess glucose variability by continuous glucose monitoring (CGM) and to demonstrate the risk of acute ischemic stroke patients with glucose levels outside of the glucose management recommendations. METHODS: Patients with ischemic stroke admitted within 7 days after onset were prospectively enrolled, and their blood glucose levels were monitored every 15 minutes for 72-hour period using the FreeStyle Libre Pro. Multivariate logistic regression analyses were used to analyze potential predictors for hyperglycemic (>180 mg/dL) and hypoglycemic (<60 mg/dL) events. RESULTS: A total of 39 acute ischemic stroke patients (mean age 75.9 ± 11.5 years) were enrolled, and CGM was started from 58.6 ± 41.9 hours after stroke onset. CGM showed hypoglycemic events in 19 patients and hyperglycemic events in 21 patients, and the frequencies of hypo- and hyperglycemic events during CGM were 10.1 ± 15.7% and 11.9 ± 22.5%, respectively. Hypoglycemic events were mainly observed in the night-time in patients with normoglycemia at admission. Logistic regression analyses demonstrated significant associations between the blood glucose level at admission and hypo- and hyperglycemic events on CGM. CONCLUSIONS: This study of CGM found that many stroke patients have blood glucose levels outside the recommended guideline range in the acute phase. Blood glucose level on admission may be used as a predictor for hypo- and hyperglycemic events after admission.

Acute onset bilateral hearing loss in dorsomedial pontine hemorrhage: A Case report.

RATIONALE: Nontraumatic pontine hemorrhage represents approximately 10% of all cases of nontraumatic intracranial hemorrhage. The predominant cause and symptom of pontine hemorrhage are hypertension and disturbance of consciousness, respectively. PATIENT CONCERNS: A 64-year-old man was transported to hospital by ambulance for sudden articulation disorder and right leg paralysis. He was neurologically alert with mild dysarthria, right leg paralysis, and increased deep tendon reflex in all limbs. DIAGNOSIS: Plain head computed tomography showed an approximately 1.5 mL hemorrhage in the dorsomedial pons. INTERVENTION: He was admitted to the Stroke Care Unit and received antihypertensive therapy. OUTCOMES: Around the time of admission, bilateral hearing loss suddenly developed with poorly defined wave V shown bilaterally on auditory brainstem response testing. As the hematoma subsequently resolved, the bilateral hearing loss recovered sufficiently to enable everyday conversation. LESSONS: We report herein a rare case of acute onset bilateral hearing loss caused by nontraumatic pontine hemorrhage. Pontine hemorrhage is often associated with disturbance of consciousness; however, care is required as latent communication disorder due to impaired hearing is possible regardless of the state of consciousness.

Efficacy of perampanel for anti-N-methyl-D-aspartate receptor encephalitis: A case report.

RATIONALE: We report this 1st case because perampanel may be effective against the seizures and abnormal behavior that occur in anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis. PATIENT CONCERNS: The patient was a healthy 26-year-old woman who suddenly developed seizures and exhibited abnormal behavior. DIAGNOSES: NMDAR encephalitis was diagnosed based on positive NMDAR antibody on cerebrospinal fluid analysis. INTERVENTIONS: Treatment with anticonvulsants and sedatives was started immediately, along with steroid pulse therapy and plasmapheresis, but these measures did not adequately control the repeated seizures and abnormal behavior. However, with the addition of oral perampanel, an α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor antagonist, the seizures and abnormal behavior promptly disappeared. OUTCOMES: The patient was transferred to the rehabilitation hospital and returned to her job. LESSONS: It appears that perampanel rapidly eliminated these clinical features by inhibiting inflow of abnormal glutamic acid and attenuating nerve hyperexcitability by acting as a selective and noncompetitive antagonist of AMPA receptors that had increased in the postsynaptic membrane due to anti-NMDAR encephalitis. To the best of our knowledge, there are no other reports showing that perampanel was effective against anti-NMDAR encephalitis. This case suggests that perampanel may be effective against the seizures and abnormal behavior that occur in anti-NMDAR encephalitis.

Reversible Cerebral Vasoconstriction Syndrome after Administering Etanercept during Puerperium.

Our objective is to clarify relationship between reversible cerebral vasoconstriction syndrome and administrating etanercept during puerperium. Several lines of evidence have suggested tumor necrosis factor (TNF) as a mediator of vascular dysfunction associated with estrogen deficiency. A 32-year-old woman resumed etanercept (25 mg/week), a TNF inhibitor, which had been discontinued during pregnancy, because of the deterioration of rheumatoid arthritis. She was admitted to our hospital with upper right quadrant blindness and mild right hemiparesis accompanied by pulsating left occipital pain, which had appeared 4 hours after restarting etanercept (25 mg/week). Magnetic resonance imaging and angiography revealed acute left hippocampal infarction with multiple segmental stenoses of the main intracranial arteries. Reversible cerebral vasoconstriction syndrome was diagnosed based on improvement of the multiple stenoses on magnetic resonance angiography on hospital day 17. A causal relationship was considered to exist between TNF inhibition by etanercept and multiple cerebral vasoconstrictions with brain infarct in this puerperant.

Magnetic Resonance Imaging White Matter Hyperintensity as a Predictor of Stroke Recurrence in Patients with Embolic Stroke of Undetermined Source.

BACKGROUND AND PURPOSE: This study aimed to investigate factors associated with stroke recurrence and new-onset atrial fibrillation (AF) in patients with embolic stroke of undetermined source (ESUS). METHODS: Between January 2005 and March 2012, a total of 1514 consecutive patients were admitted to our hospital with a diagnosis of acute ischemic stroke within 7 days after onset. Of these, 236 patients met the diagnostic criteria for ESUS. A retrospective analysis was performed of the following characteristics of these ESUS patients: medical history, comorbidities, and magnetic resonance imaging (MRI) findings including the deep and subcortical white matter hyperintensity (DSWMH) grade, drugs used for preventing recurrence, and clinical information such as NIH Stroke Scale scores on admission and outcomes evaluated by modified Rankin scale. The rate of recurrence after discharge and the frequency of new-onset AF were also determined. RESULTS: There were 236 ESUS patients (141 men, mean age 70.2 ± 12.1 years). During the follow-up period, ranging from 7 days to 12.9 years (median 54.3 months), 32 (13.6%) and 44 (18.6%) of these patients had a recurrent ischemic stroke and new-onset AF, respectively. The most prevalent subtype of recurrent ischemic stroke was ESUS itself; this type of stroke occurred in 19 (59.3%) patients. AF was observed at stroke recurrence, but only 2 patients were diagnosed with cardioembolism. Multivariate analysis with a Cox proportional hazard model demonstrated that DSWMH grade greater than or equal to 3 was significantly associated with both recurrent ischemic stroke (hazard ratio 3.66, 95% confidence interval 1.69-7.92, P = .001) and new-onset AF (2.00, 1.03-3.90, .04). CONCLUSIONS: MRI classification of white matter hyperintensity could be effectively used as a predictor for recurrent ischemic stroke and new-onset AF in patients with ESUS.

Rheumatoid meningitis presenting with a stroke-like attack treated with recombinant tissue plasminogen activator: a case presentation.

BACKGROUND: Rheumatoid meningitis presenting with a stroke-like attack (RMSA) is a rare manifestation of rheumatoid arthritis (RA). When the patients arrive within the time-window for recombinant tissue plasminogen activator (rt-PA) infusion therapy, no diagnostic protocol has been established. CASE PRESENTATION: A 55-year-old woman was brought by ambulance to our hospital with complaints of sudden-onset dysarthria and left arm numbness. The National Institutes of Health Stroke Scale (NIHSS) score was 5, and the Alberta Stroke Program Early CT Score was 8. She was diagnosed with acute embolic stroke. At 4 h, 6 min after onset, intravenous administration of rt-PA (alteplase, 0.6 mg/kg) was started. Her neurological deficits improved rapidly, and her NIHSS score was 1. Brain MRI was then performed. There was no hemorrhagic transformation, but the MRI findings were not compatible with ischemic stroke. She had a past history of RA diagnosed 6 months earlier, and she had been treated with methotrexate (10 mg daily). She was diagnosed with RMSA, and continuous infusion of methylprednisolone 1000 mg daily was started for 3 days. The high signal intensity on the FLAIR image disappeared. CONCLUSION: CT-based decision-making for rt-PA injection is reasonable, but MRI is needed for the early diagnosis of RMSA. In this case, it is particularly important that neither adverse events nor bleeding complications were observed, suggesting the safety of CT-based thrombolytic therapy in RMSA.

The utility of superb microvascular imaging for the detection of deep vein thrombosis.

Superb microvascular imaging (SMI) reduces motion artifacts significantly and allows visualization of low-velocity blood flow in vessels; thus, thrombi are clearly demonstrated compared to conventional B-mode and color Doppler imaging. Ultrasonographic images of the lower extremities of a 69-year-old woman with acute ischemic stroke complicated with deep vein thrombosis (DVT) are presented. Because SMI allows visualization of low-velocity blood flow, echo contrast between the thrombus and the surrounding flow makes it possible to clearly visualize the thrombus. SMI is a useful method to evaluate DVT, especially early after thrombus formation when it is difficult to delineate size and length because of echolucency.