Simultaneous Presentation of Brainstem and Cerebellar Posterior Reversible Encephalopathy Syndrome With Acute Cerebral Infarction.

Posterior reversible encephalopathy syndrome (PRES) and cerebral infarction are both caused by hypertension, but they rarely occur together. If they do coexist, the selection of a management strategy is difficult because of their pathologic differences. Here, we present an uncommon case of brainstem and cerebellar PRES combined with acute lacunar infarction. For this patient, we used an aggressive blood pressure-lowering regimen during the acute phase of his condition. Once the cerebral edema caused by PRES began to improve, antiplatelet therapy was initiated. The treatment was ultimately successful, and the patient was discharged home. A return to work is now planned. Given the rarity of this combination of conditions and a lack of published evidence for management, our report will contribute to the literature concerning the treatment for this combination of conditions.

Resumption of Direct Oral Anticoagulants in Patients with Acute Spontaneous Intracerebral Hemorrhage.

BACKGROUND: Decisions regarding whether and when to resume direct oral anticoagulants (DOAC) after acute intracerebral hemorrhage (ICH) are challenging. We examined the timing of DOAC resumption and factors that influence decision-making in DOAC resumption. METHODS: We retrospectively analyzed 43 patients with ICH who were treated with DOAC for nonvalvular atrial fibrillation before ICH onset. All patients were divided into 2 groups (resumption of DOAC and no resumption of DOAC) during hospitalization. Clinical backgrounds, laboratory data, and stroke severity were compared between the groups. RESULTS: DOAC were resumed in 19 of 39 (49%) acute ICH survivors and were not resumed in 24 patients, including 4 deceased patients. The National Institutes of Health Stroke Scale score at admission tended to be higher in the no resumption group (median, 17) than in the resumption group (median, 6) (P = .119). The modified Rankin Scale score was slightly poorer in the no resumption group (median, 4) than in the resumption group (median, 3) (P = .070). In the resumption group, DOAC were resumed at a median of 11 days (interquartile range, 5-21 days) after ICH onset. The modified Rankin Scale score at discharge was positively correlated with the days of DOAC resumption (R2 = .31, P = .013). CONCLUSIONS: In half of patients, DOAC were resumed relatively early after ICH onset. Early resumption of DOAC for ICH in patients with nonvalvular atrial fibrillation is considered to be safe. The functional outcome was associated with not only resumption of DOAC but also the timing of resumption.

Bilateral persistent hypoglossal arteries: a case report and literature review.

Bilateral persistent hypoglossal arteries (PHAs) are extremely rare, with only 5 cases reported in the English-language literature. Using magnetic resonance angiography, we diagnosed a case in which the left side was a typical PHA and the right side was presumed a PHA variant that supplied only the posterior inferior cerebellar artery.

The dose of direct oral anticoagulants and outcomes of intracerebral hemorrhage: Preliminary findings.

OBJECTIVES: The effect of a direct-acting oral anticoagulant (DOAC) dose on intracerebral hemorrhage (ICH) severity and outcome remains unclear. The aim of this study is to clarify the frequency of off-label dosing of DOAC treatments in ICH patients and compare clinical characteristics. PATIENTS AND METHODS: We studied 43 patients with ICH who were treated with DOAC for nonvalvular atrial fibrillation before the onset of ICH. DOAC treatments were categorized into three groups based on the following doses: optimal dose, under-dose, and overdose. RESULTS: Overall, 31 patients were optimally dosed, 10 were under-dosed, and 2 were overdosed. CHADS2 and CHA2DS2-VASc scores were the highest in the overdose group (median, 4, 6, respectively) and the lowest in the optimal dose group (median, 2, 4, respectively) (p = 0.006, p = 0.005, respectively). ICH severity measured using the National Institutes of Health Stroke Scale scores was the highest in the overdose group (median, 26.5) and the lowest in the under-dose group (median, 6.5) (p = 0.244). Larger initial hematoma volume was observed in the overdose group. The ratio of good outcome (modified Rankin Scale score ≤ 2) was higher in the under-dose group (40%) than the other groups, but this difference was not significant. CONCLUSION: Our study shows only a few patients received overdosing of a DOAC before the onset of ICH, and they were associated with poorer functional outcomes. Conversely, under-dosing was associated with better functional outcomes than the other groups.

Functional Outcomes of Decompressive Craniectomy in Patients with Malignant Middle Cerebral Artery Infarction and Their Association with Preoperative Thalamus Deformation: An Analysis of 12 Patients.

Objective Decompressive craniectomy (DC) in patients with malignant middle cerebral artery (MCA) infarction is known to decrease the mortality rate. However, the functional outcomes (communication and oral intake) of this procedure remain unclear. Most patients with malignant MCA infarction exhibit a loss of consciousness, which may be principally governed by the thalamus. We herein investigated the functional outcomes of DC at 90 days after the onset of malignant MCA infarction and their association with preoperative thalamus deformation, which can occur due to pressure and edema. Methods Twelve of 2,692 patients with acute cerebral infarction were diagnosed with malignant MCA infarction and underwent DC. We evaluated preoperative thalamus damage using brain computed tomography and its association with communication and oral intake abilities and the modified Rankin Scale (mRS) and Barthel index scores at 90 days after stroke onset. Results The mRS score at 90 days was 0-4 in five patients. Seven patients could communicate immediately after surgery, while five could do so by 90 days. Five patients were able to resume the oral intake of food at 90 days. All patients with preoperative thalamus deformation showed a poor recovery, while those with absent or slight preoperative thalamus deformation showed a good recovery. Conclusion Patients with preoperative thalamus deformation caused by pressure and edema show a poor oral intake and communication abilities after DC, suggesting that preoperative thalamus deformation is a predictor of poor functional outcomes after DC in patients with malignant MCA infarction.

Clinical Features of Ischemic Stroke during Treatment with Dabigatran: An Association between Decreased Severity and a Favorable Prognosis.

OBJECTIVE: Anticoagulation therapy with warfarin is associated with a favorable prognosis in ischemic stroke. Dabigatran, a new oral anticoagulant, is widely used to prevent ischemic stroke in non-valvular atrial fibrillation (NVAF) patients. However, its association with decreased severity and a favorable prognosis once ischemic stroke has occurred remains unknown. METHODS: We retrospectively reviewed all the patients with NVAF-associated ischemic stroke admitted to our hospital from April 2011 to December 2014 and included those who received dabigatran therapy. We assessed whether the patients were under regular use of the drug or discontinuance and classified them into 2 groups, the treatment and discontinuation groups. Clinical data, including the age, sex, ASCOD stroke phenotype, NVAF type, prescribed drug dose, comorbidities, CHADS2 score, renal function, National Institute of Health Stroke Scale (NIHSS) score on admission, modified Rankin scale (mRS) score at discharge, D-dimer, and brain natriuretic peptide, were investigated and compared between the groups. RESULTS: Nine patients were under regular dabigatran therapy, and 6 were under discontinuance of the drug. The age, sex, ASCOD stroke phenotype, NVAF type, comorbidities, renal function, and CHADS2 scores did not differ between the 2 groups; however, the NIHSS scores were significantly lower in the treatment group. The mRS scores at discharge were additionally decreased in the treatment group. Moreover, the D-dimer scores were lower in the treatment group, thus suggesting a possible role in the decreased stroke severity. CONCLUSION: Dabigatran may therefore decrease the severity of ischemic stroke, even if ischemic stroke occurs.

Platelet-endothelial cell interaction in brain microvessels of angiotensin II type-2 receptor knockout mice following transient bilateral common carotid artery occlusion.

The purpose of this study was to investigate the behavior of platelets (rolling and adhesion) in cerebral microvessels of angiotensin II type-2 receptor-knockout (AT2RKO) mice after transient bilateral carotid artery occlusion using intravital fluorescence microscopy. Twenty AT2RKO mice, consisting of 11 mice in the sham group and 9 mice in the ischemia reperfusion group (reperfusion after 15 min of bilateral, total carotid artery occlusion) were used in this study. The hole traversed the bone and dura mater, but arachnoid, pia mater, and cerebral parenchyma were preserved. Platelets were harvested from donor mice and stained using carboxyfluorescein diacetate succinimidyl ester. The number of platelets showing rolling and adhesion to pial vessels in AT2 deficient mice at 3 and 6 h after cerebral ischemia reperfusion was significantly higher than that in the sham group (P < 0.05). In addition, AT2 receptor has an inhibitory role in platelet rolling and adhesion after cerebral ischemia reperfusion.

Ischemic stroke with essential thrombocythemia: a case series.

BACKGROUND: Essential thrombocythemia (ET) is considered a rare cause of stroke partly because it is not detected if the platelet count is not elevated. However, early detection of ET is important because thrombosis can recur frequently, unless adequately treated. METHODS: We retrospectively collected data from 10 stroke cases with ET. Clinical characteristics, location of stroke, laboratory data (platelet and leukocyte count, hemoglobin, and JAK2 V617F mutation), and treatment were reviewed. RESULTS: The population consisted of 7 women and 3 men aged 18-83 years. Most patients had atherosclerotic risk factors. Half of the patients had a history of ischemic stroke. In 8 patients, ischemic stroke was the first manifestation of ET. Of 13 acute cerebrovascular events, 4 were transient ischemic attacks and 9 were cerebral infarctions. Three patients presented with watershed-type infarcts without large artery stenosis. Two patients had atherosclerotic stenosis of the large artery and experienced atherothrombotic infarction. The mean platelet count was 966 ± 383 × 10(9)/L. JAK2 V617F mutation was found in 5 of 7 patients. Despite treatment with combined antiplatelet and cytoreductive therapy in all patients, 3 experienced recurrent ischemic stroke. CONCLUSIONS: These findings suggest that ET is an adjunctive risk factor for stroke and the patients with ET are subject to watershed-type infarcts even in the absence of large artery stenosis. Early diagnosis of ET and strict management of vascular risk factors may help prevent additional cerebrovascular events.

Left carotid-anterior cerebral artery anastomosis diagnosed by MR angiography: a case report.

Anastomosis of the carotid-anterior cerebral artery (ACA) is a rare anomalous vessel that arises from the internal carotid artery (ICA) at the level of the ophthalmic artery and takes an infraoptic and prechiasmatic path to anastomose with the ACA. It has known right-sided predominance. We report the case of an 83-year-old man with a left carotid-ACA anastomosis that was diagnosed by magnetic resonance (MR) angiography from the neck to the head during investigation of transient left hemiplegia. The right ICA was occluded at its origin. Our literature search revealed only six reported cases of left carotid-ACA anastomoses. We believe ours is the first case diagnosed by MR angiography.

Relationship between smoking and responsiveness to clopidogrel in non-cardiogenic ischemic stroke patients.

OBJECTIVE: Clopidogrel is used to prevent the recurrence of non-cardiogenic ischemic stroke, but individual responsiveness to the drug varies. Moreover, it is known that smoking, which is a risk factor for ischemic stroke, affects the drug's pharmacokinetics. The objective of the present study was to investigate a possible relationship between smoking and responsiveness to clopidogrel in non-cardiogenic ischemic stroke patients. METHODS: The study involved 209 non-cardiogenic ischemic stroke patients who were administered oral clopidogrel at a dosage of 75 mg/day for at least 1 week. Platelet aggregation in response to adenosine diphosphate (20 µM) was measured in each patient using the VerifyNow P2Y12 Assay. Platelet aggregation and the incidence of resistance to clopidogrel were compared between a smokers group (70 patients) and a non-smokers group (139 patients). Clopidogrel resistance was defined as a P2Y12 Reaction Units (PRU) value >230 and/or % inhibition <20%. RESULTS: The mean PRU was 128.3±85.5 in the smokers group and 167.7±86.6 in the non-smokers group (p=0.002). The incidence of PRU >230 was 12.9% (9 patients) in the smokers group and 25.9% (36 patients) in the non-smokers group (p=0.033). The mean % inhibition was 48.6±30.7% in the smokers group and 36.9±27.6% in the non-smokers group (p=0.009). The incidence of patients with % inhibition <20% was 24.3% (17 patients) in the smokers group and 34.5% (48 patients) in the non-smokers group (p=0.155). CONCLUSION: The incidence of clopidogrel resistance was lower in the non-cardiogenic ischemic stroke patients who were smokers, thus indicating that these patients' responsiveness to this drug may be enhanced.

Clinical outcomes of persistent and paroxysmal atrial fibrillation in patients with stroke.

BACKGROUND: We compared the clinical outcomes of persistent atrial fibrillation (PeAF) and paroxysmal atrial fibrillation (PAF) in patients with cardioembolic stroke caused by nonvalvular atrial fibrillation (NVAF) because the nature of the fibrillation can cause persistent cerebral infarction. METHODS: We classified 619 of 964 patients hospitalized with cardioembolic stroke between April 2007 and December 2013 within 24 hours of onset as having PeAF (n = 447) and PAF (n = 172) according to a retrospective analysis of their clinical records, including National Institutes of Health Stroke Scale (NIHSS) scores on admission, clinical outcomes (modified Rankin Scale [mRS] scores) at 90 days after admission, and major cerebral artery occlusion. RESULTS: The PeAF group was significantly older (P < .001) and had a higher prevalence of hypertension (P = .007), diabetes (P = .039), heart failure (P = .004), previous coronary artery disease (P = .002) and cerebral infarction (P < .001), medication with anticoagulants (P < .001), and elevated blood glucose on admission (P = .002). Neurologic severity assessed by NIHSS scores on admission was significantly worse in the PeAF than in the PAF group (P < .001). Significantly more patients in the PAF group had favorable outcomes (mRS, 0-2) after 90 days (P < .001). The incidence of major cerebral artery occlusion was significantly higher in the PeAF group (P < .001). CONCLUSIONS: Patients with PeAF and cardioembolic stroke due to NVAF had more severe neurologic deficits on admission, more frequent major arterial occlusion, and poorer outcomes than those with PAF.

Research article: clinical characteristics of isolated anterior cerebral artery territory infarction due to arterial dissection.

BACKGROUND: Isolated brain infarction in the anterior cerebral artery (ACA) territory is rare, and its etiology has not yet been fully elucidated. Thus, we aimed to determine the etiologic and clinical characteristics of patients with isolated ACA territory infarction due to arterial dissection. METHODS: Of 2315 patients with acute cerebral infarction admitted to our hospital between April 2007 and September 2013, 34 patients (1.5%; 28 men, 6 women; mean age, 65 ± 15 years) suffered isolated ACA territory infarction. We performed cranial magnetic resonance (MR) imaging and MR angiography for all the patients. Whenever possible, we also performed 3-dimensional computed tomography angiography, digital subtraction angiography, and MR cisternography to diagnose the stroke subtype. RESULTS: The stroke subtypes of the 34 patients with isolated ACA territory infarction were atherothrombotic infarction, cardioembolic infarction, arterial dissection, and unclassified in 11 patients (32%), 11 patients (32%), 11 patients (32%), and 1 patient (3%), respectively. The mean ages at onset were 48 ± 9 and 72 ± 11 years in the dissection and nondissection groups, respectively (P < .001). Headaches were present at onset in 4 patients (36%) and 1 patient (4%) with and without dissection, respectively (P = .026). Blood pressure at onset was significantly higher among patients with dissection (systolic, 179 ± 34 mm Hg; diastolic, 102 ± 17 mm Hg) than among patients without dissection (systolic, 155 ± 30 mm Hg; diastolic, 86 ± 21 mm Hg; P < .05), and d-dimer values were significantly lower among patients with dissection (P = .034). Favorable clinical outcome (modified Rankin Scale score, 0-2) at discharge was achieved in 9 patients (82%) and 10 patients (43%) with and without dissection, respectively (P = .035). CONCLUSIONS: Patients with isolated ACA territory infarction demonstrated a relatively high frequency of dissection (32%). Patients with dissection were younger, had a higher frequency of headaches, and demonstrated more favorable prognoses than patients without dissection.

Cerebral sinovenous thrombosis in a patient with transient eosinophilia.

A 67-year-old man with a history of prostatic hypertrophy developed behavioral anomalies and a fever. At admission, diffusion-weighted brain magnetic resonance imaging (MRI) indicated a high-intensity signal lesion on both sides of the cerebral hemisphere. Immediately after hospitalization, he developed paralysis of the left side of the body. Diffusion-weighted MRI indicated hemorrhagic changes in the right and left parietal lobes and right occipital lobe. Magnetic resonance venography indicated superior sagittal sinus occlusion. The blood test results indicated transient eosinophilia. Cases of thrombosis with idiopathic eosinophilia have been reported, but this is the first known case of cerebral sinus thrombosis with transient eosinophilic leukocytosis.

Clinical characteristics of cardioembolic transient ischemic attack: comparison with noncardioembolic transient ischemic attack.

BACKGROUND: Previous studies show that 6%-31% of transient ischemic attacks (TIA) were caused by cardiogenic cerebral embolism (cardioembolic TIA). As prompt initiation of therapy is essential in TIA to prevent subsequent strokes, determining their cause is important. In this study, we aim to determine the features of cardioembolic TIA and to compare them with those of noncardioembolic etiology. METHODS: We retrospectively reviewed patients with a tissue-defined TIA who were admitted to our hospital from April 2007 to August 2013. The etiology was categorized according to Trial of Org 10172 in Acute Stroke Treatment, and TIA of cardioembolic origin and cervicocerebrovascular etiology (noncardioembolic TIA) were included in this study. Those with 2 or more possible causes or undetermined etiologies were excluded. Age, sex, comorbidities, ABCD2 score, and CHADS2 score were assessed and compared between the 2 groups. RESULTS: There were no significant differences in the neurologic symptoms and their duration, morbidities of hypertension, diabetes, and dyslipidemia between the 2 groups. Coronary and peripheral artery diseases were more common in the cardioembolic TIA group (18.4% vs. 6.9%). Incidences of prior stroke and cerebral infarction determined by MRI were similar between the 2 groups. The ABCD2 score showed a similar distribution, but the CHADS2 score was significantly different; the cardioembolic TIA group showed a higher score (P = .005). CONCLUSIONS: Clinical features are similar in tissue-defined TIA of cardioembolic and noncardioembolic etiologies. The CHADS2 score can be useful in assessing the probability of cardioembolic TIA.

Effects of rosuvastatin on serum lipids and arteriosclerosis in dyslipidemic patients with cerebral infarction.

BACKGROUND: We investigated the effect of rosuvastatin, 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitor, on serum lipids and arteriosclerosis in dyslipidemic patients with cerebral infarction. METHODS: The subjects were 24 patients with noncardiogenic cerebral infarction complicated by dyslipidemia (low-density lipoprotein cholesterol [LDL-C] ≥ 140 mg/dL). Serum lipids and highly sensitive C-reactive protein (hs-CRP) were measured at the start of the study and at 3 and 12 months after the initiation of oral rosuvastatin (5 mg/day). Cardio-ankle vascular index (CAVI), intima-media thickness (IMT), and plaque score (PS) were also determined at the start of the study and at 12 months. RESULTS: Of the 24 patients admitted, 17 were eligible for statistical analysis. Total cholesterol (TC), LDL-C, and non-high-density lipoprotein cholesterol (non-HDL-C) (mean [standard deviation {SD}], mg/dL) were significantly decreased at 3 months (TC, 149.4 [20.4]; LDL-C, 78.7 [18.6]; non-HDL-C, 94.6 [21.7]) and at 12 months (TC, 154.9 [27.2]; LDL-C, 82.5 [23.3]; non-HDL-C, 100.2 [28.8]) compared with the baseline data (TC, 232.8 [29.7]; LDL-C, 162.2 [21.2]; non-HDL-C, 183.0 [27.7]). The serum hs-CRP level (mean [SD], ng/mL) was 1053.1 [818.8] at baseline, 575.2 [481.8] at 3 months, and 488.1 [357.7] at 12 months. The decrease in this parameter at 12 months was statistically significant. There was a decrease, although not statistically significant, in CAVI (mean [SD]) at 12 months (right [Rt.] 8.7 [.9]; left [Lt.] 8.6 [1.0]), compared with baseline (Rt. 9.1 [1.1]; Lt. 9.0 [1.1]). The max-IMT (mean [SD], mm) was (Rt. 2.11 [.97]; Lt. 2.01 [.75]) at baseline and (Rt. 2.18 [.82]; Lt. 2.06 [.79]) at 12 months of study treatment. The PS (mean [SD], mm) was 8.93 [4.33] at baseline and 9.61 [4.79] at 12 months; neither parameter showed a significant change. CONCLUSIONS: Rosuvastatin at 5 mg/day significantly reduced serum levels of TC, LDL-C, non-HDL-C, and hs-CRP in dyslipidemic patients with cerebral infarction. No significant change in CAVI, max-IMT, or PS was noted after the study treatment.

Intestinal P-glycoprotein expression is multimodally regulated by intestinal ischemia-reperfusion.

PURPOSE: Reactive oxygen species (ROS) have multiple physiological effects that are amount-dependent. ROS are one of the causes of intestinal ischemia-reperfusion (I/R) injury. In this study, we investigated whether the amount of ROS and the degree of intestinal I/R injury affect the expression level of P-glycoprotein (P-gp). METHODS: . We used hydrogen peroxide (H2O2) as ROS in in vitro experiments. Intestinal I/R model rats, which were subjected 15-min ischemia (I/R-15), were used in in vivo experiments. RESULTS: P-gp expression in Caco-2 cells was increased in response to 1 µM of H2O2 but decreased upon exposure to 10 mM of H2O2. We previously reported that P-gp expression is decreased after intestinal I/R with 30-min ischemia (I/R-30), which time a large amount of ROS is generated. I/R-15 induced slightly less mucosal and oxidative injury than did I/R-30. P-gp expression in the jejunum was increased at 1 h after I/R-15, and ileal paracellular permeability was increased. The blood concentration of tacrolimus, a P-gp substrate, was lower during 0-20 min but was higher during 40-90 min post-administration compared with that in the sham-operated rats. P-gp expression in the ileum was decreased at 6 h after I/R-15, due to abnormal localization of P-gp, resulting in a high blood tacrolimus concentration in rats reperfused for 6 h. CONCLUSIONS: ROS multimodally regulate P-gp expression depending on its amount. This is important for understanding the pattern of P-gp expression after intestinal I/R.

Clinical review of 24 patients with acute cholecystitis after acute cerebral infarction.

OBJECTIVE: Acute cholecystitis (AC) after acute cerebral infarction is rare and has not been fully investigated. Because patients with acute cerebral infarction often cannot complain of abdominal pain due to loss of consciousness, hemiparesis and aphasia, delays in diagnosis may increase the severity of the condition. It is clearly important to identify symptoms, reach a diagnosis and provide treatment as soon as possible. The purpose of this study was to investigate the clinical features of AC after acute cerebral infarction. METHODS: Among the 1,682 patients with acute cerebral infarction admitted to our hospital between April 2007 and July 2012, AC after acute cerebral infarction was diagnosed in 24 (1.4%). Data regarding age, sex, past history, fasting period, period from admission to the onset of cholecystitis, clinical type, severity of cholecystitis, diffusion-weighted imaging Alberta Stroke Program Early Computed Tomography Score, National Institutes of Health Stroke Scale (NIHSS) score at onset and modified Rankin scale at 90 days were investigated. RESULTS: The mean age of the 24 patients (15 men, 9 women) was 74.2±11.9 years (range, 45-90 years). The clinical type was atherothrombosis in five patients, lacunar infarction in seven patients, cardiac embolism in 10 patients and dissection in two patients. The past history included atrial fibrillation in 10 (42%) patients, hypertension in 20 (83%) patients and diabetes in 11 (46%) patients. The mean duration of fasting was 10.7 days (range, 1-32 days). The mean interval between the onset of cholecystitis and admission was 8.3 days (range, 0-24 days). The median NIHSS score at onset of cerebral infarction was 10, and 23 (96%) patients were bedridden at the onset of cholecystitis. CONCLUSION: AC after acute cerebral infarction was frequently observed in the patients with severe hemiparesis and those who were fasted. It is important to identify symptoms, accurately diagnose the condition and provide treatment as soon as possible in order to achieve early ambulation and resumption of food intake using a feeding tube.

A case of anterior cerebral artery dissection caused by scuba diving.

A 51-year-old man was admitted with right hemiparesis during scuba diving, without headache. Brain magnetic resonance (MR) imaging depicted high-intensity areas in the left superior frontal and cingulate gyri on diffusion-weighted imaging. Dissection of the anterior cerebral artery (ACA) was detected using axial MR angiography and 3-dimensional MR cisternography. Dissection of the ACA during and after scuba diving has not been reported before. Dissection of the arteries should be included in the differential diagnosis when neurologic symptoms occur both during and after scuba diving, even if the patient does not experience headache. Furthermore, the combination of MR cisternography and MR angiography is useful to detect ACA dissection.