Cerebral microbleeds is a predictor of recurrent small vessel cerebrovascular disease: Evaluation based on the recurrent stroke pattern.

OBJECTIVES: An increased number of cerebral microbleeds (CMBs) is considered a predictive factor for recurrent small vessel cerebrovascular diseases, including lacunar infarction and non-lobar intracerebral hemorrhage (ICH). However, it is unclear which recurrent stroke pattern is mainly reflected in the number of CMBs. MATERIALS AND METHODS: This study enrolled 217 patients with their first stroke (148 deep lacunar infarctions and 69 non-lobar ICHs), between January 2009 and March 2015. The numbers of baseline and newly appearing CMBs in patients with recurrent stroke were compared with those in patients with non-recurrent stroke, and the dynamics of the number of CMBs was evaluated according to recurrent stroke patterns. RESULTS: Fifty-nine patients with recurrent stroke were included in this study. A larger number of baseline and newly appearing CMBs was significantly associated with recurrent stroke (p = 0.04, p < 0.001, respectively). Recurrent stroke patterns were divided into four types: deep lacunar infarction/deep lacunar infarction (37 patients), deep lacunar infarction/non-lobar ICH (eight patients), non-lobar ICH/deep lacunar infarction (eight patients), and non-lobar ICH/non-lobar ICH (six patients). The number of newly appearing CMBs was significantly higher in patients with deep lacunar infarction/non-lobar ICH than in those with other recurrent stroke patterns (p = 0.04). CONCLUSIONS: The number of CMBs is associated with recurrent stroke, including deep lacunar infarction and non-lobar ICH, and differs depending on the recurrent stroke patterns. The increase in the number of CMBs was strongly correlated with the deep lacunar infarction/non-lobar ICH recurrence pattern.

Intravenous Thrombolysis Improved Aphemia and Confirmed the Dominant Precentral Gyrus as the Responsible Lesion.

Aphemia is now considered an impairment of speech production. We present a case of an 89-year-old right-handed woman who received intravenous thrombolysis with a recombinant tissue plasminogen activator for the ischemic symptom "loss of speech" and recovered with an ischemic lesion of the left precentral gyrus. The patient had untreated atrial fibrillation. Neurological examination showed that her level of consciousness was alert, with normal comprehension and mild lower facial droop. Head computed tomography (CT) did not reveal a hemorrhagic lesion. To treat the acute ischemic stroke, she received a recombinant tissue plasminogen activator. Just after thrombolysis, she started to speak. Then, magnetic resonance imaging (MRI) revealed an acute ischemic infarction in the dominant precentral gyrus. Follow-up MRI revealed the peripheral middle cerebral artery territory infarction in the left precentral gyrus, but she still could speak. The symptom of "loss of speech" was considered aphemia. By intravenous thrombolysis, impaired speech production in our patient was believed to be caused by an infarction in the dominant precentral gyrus. This case also demonstrated that the rare clinical symptom was due to an ischemic stroke in the territory of the distal middle cerebral artery. Clinicians who engage in stroke care need to know the rare symptoms of aphemia in the era when mechanical thrombectomy could be considered a promising treatment option for distal medium vessel occlusion.

Walk-In Hospital Admission of Patients with Subarachnoid Hemorrhage: Clinical Presentation and Outcome.

OBJECTIVE: Neurosurgeons occasionally encounter cases of subarachnoid hemorrhage (SAH) in admitted walk-in patients, termed "walk-in SAH." However, their clinical characteristics have not been fully understood. We thus, aimed to investigate several characteristics of patients with walk-in SAH and compare them with those of patients with good grade SAH who arrived at the hospital by ambulance. METHODS: Between January 2011 and January 2018, consecutive patients with World Federation of Neurosurgical Society (WFNS) grade I and II aneurysmal SAH were enrolled. They were dichotomized into walk-in and ambulance groups, and their demographic and disease-related characteristics were compared. Furthermore, predictors associated with unfavorable outcomes were investigated in patients with walk-in SAH. RESULTS: Of 171 patients with World Federation of Neurosurgical Society grade I and II SAH, 68 (39.8%) were categorized as walk-in SAH. The mean time for diagnosis in patients with walk-in SAH was significantly longer than that in patients who arrived by ambulance (P < 0.01). Multivariate analysis demonstrated that a lower rate of hypertension, high grades on the Barrow Neurological Institute scale, and Early Brain Edema Score were significantly associated with walk-in SAH (odds ratio [OR] 0.44, 95% confidence interval [CI] 0.21-0.91, P = 0.03; OR 0.32, 95% CI 0.13-0.76, P = 0.007; OR 0.11, 95% CI 0.02-0.51, P < 0.0001, respectively). Additionally, severe angiographic vasospasm was a significant predictor of unfavorable outcomes in walk-in SAH (OR 37.7, 95% CI 1.10-1290.90, P = 0.04). CONCLUSIONS: Patients with walk-in SAH exhibit radiological characteristics associated with a more favorable outcome among patients with good grade SAH. Therefore, these patients may have a positive prognosis.

Predictive Factors of Functional Outcome in World Federation of Neurosurgical Societies Grade V Subarachnoid Hemorrhage.

OBJECTIVE: Patients with World Federation of Neurosurgical Societies (WFNS) grade V subarachnoid hemorrhage (SAH) frequently have poor outcomes. The current understanding of the predictors of functional outcome only in WFNS grade V SAH is limited. METHODS: Patients with WFNS grade V SAH were retrospectively analyzed between April 2008 and August 2019. Surgical treatment is commonly delayed until clinical improvement is observed using a less aggressive approach. Clinical and radiologic data on admission were assessed, and disease-related characteristics were compared between patients with favorable outcomes (modified Rankin Scale score 0-3) and those with unfavorable outcomes (modified Rankin Scale score 4-6). RESULTS: A total of 144 patients were included, and 22 patients (15.3%) achieved favorable outcomes, whereas 122 patients (84.7%) had unfavorable outcomes. Surgical aneurysm repair was performed in all patients with favorable outcomes and in 21.3% of those with unfavorable outcomes. Multivariate analysis showed that Glasgow Coma Scale score of 3, high-grade Early Brain Edema Score, absence of bilaterally light reflex and neurologic improvement, and hypertension were significantly associated with unfavorable outcomes (odds ratio [OR], 9.54, P = 0.03; OR, 5.37, P = 0.04; OR, 11.80, P = 0.009; OR, 0.14, P = 0.02 and OR, 6.53, P = 0.04, respectively). CONCLUSIONS: The final outcome of patients with WFNS grade V SAH was still poor and highly predicted by Glasgow Coma Scale score of 3, high-grade Early Brain Edema Score, absence of bilaterally light reflex and neurologic improvement, and a history of hypertension. The efficacy of aggressive surgical treatment for these patients remains controversial, and the indications should be clearly defined in patients with desolate clinical status on admission.

Breathing irregularities before sleep onset on polysomnography in patients with heart diseases.

PURPOSE: Severe cardiac dysfunction can manifest with diurnal breathing irregularity. However, it remains to be clarified whether or not diurnal breathing irregularity is observed in patients with heart diseases, including relatively mild chronic heart failure (CHF), compared to those without heart diseases. METHODS: In this cross-sectional study, consecutive inpatients who were admitted for evaluation of sleep-disordered breathing were enrolled. We extracted 3.5 min of stable respiratory signals before sleep onset using polysomnography, analyzed the airflow data using fast Fourier transform, and quantified breathing irregularities using Shannon entropy S. RESULTS: A total of 162 subjects were evaluated. Among these, 39 subjects had heart diseases, including ischemic heart disease (IHD), atrial fibrillation (Af), CHF, and a history of aortic dissection. The values of Shannon entropy S of airflow signals in subjects with heart diseases were significantly higher than in those without heart diseases (p < 0.001). After excluding CHF, the Shannon entropy S was also significantly higher in subjects with heart diseases than in those without heart diseases (p < 0.001). The values of Shannon entropy S were significantly correlated with plasma brain natriuretic peptide levels (r = 0.443, p < 0.001). Although the values were also significantly correlated with body mass index, the presence of heart diseases was independently associated with breathing irregularity in the multiple logistic analysis. Matching analysis revealed consistent differences between subjects with heart diseases and without heart diseases. CONCLUSION: Breathing irregularity was observed before sleep onset in subjects with heart diseases who underwent polysomnography to diagnose sleep-disordered breathing.

[The Analysis of the Thickness of a Cerebral Aneurysm:Can Predict the Translucent-type of Unruptured Middle Cerebral Artery Aneurysm Preoperatively?]

OBJECT: The rupture risk of cerebral aneurysms is determined by various factors. However, it is not clear whether the thickness of the aneurysm wall also influences the rupture risk. In this study, under the assumption that thin-walled aneurysms have a higher rupture risk compared with thick-wall aneurysms, we evaluate the usefulness of computed fluid dynamics(CFD)to identify thin-walled cerebral aneurysms. METHODS: Fifty-four unruptured middle cerebral aneurysms from 53 patients were analyzed using CFD before the operation. We divided these aneurysms into two groups: translucent-type aneurysms and others. To analyze the difference of these groups, individual elements(age, gender, volume, and aspect ratio)and hemodynamic factors(wall shear stress[WSS], flow coefficient, and flow coefficient per volume)were examined using CFD. RESULTS: Univariate analysis detected significant relationships between the translucent-type aneurysms and gender, aspect ratio, WSS and flow coefficient per volume. Multiple logistics regression also identified a significant relationship with gender and flow coefficient per volume. The receiver operating characteristic curve demonstrated that the flow coefficient per volume could predict translucent-type aneurysms(area under the curve 0.84, cut-off value 1.32, sensitivity 76.2%, and specificity 87.9%). CONCLUSION: Gender and the flow coefficient per volume could predict translucent-type aneurysms of the middle cerebral artery. CFD analysis might be a useful tool to predict translucent-type aneurysms.

[Characteristics of Headache and Neck Pain in Spontaneous Vertebral Artery Dissections].

PURPOSE: Sudden onset severe occipital/nuchal pain is believed to be a typical symptom of vertebral artery dissection(VAD). However, recent developments in diagnostic imaging have suggested that VAD is not always associated with such pain. This study aimed to analyze the clinical features of initial symptoms in patients with VAD. METHODS: In total, this study included 29 consecutive patients who were referred to our hospital because of only headache and/or nuchal pain due to VAD between 2011 and 2016. In this study, their clinical features were precisely assessed, including the pain location, onset pattern, duration, intensity, disease period, diagnosis modality, and prognosis. Both MRI and MRA were performed for all subjects. Cerebral angiography and thin-slice T1-weighted MRI were additionally performed in selected cases. RESULTS: Of the 29 patients, 23 presented with occipital headache and/or nuchal pain. The pain was persistent in 26/29 and ipsilateral in 29/29. However, only 16/29 reported a typical sudden onset. Only 12/29 complained of severe pain, while the other 17/29 presented with dull pain. The mean interval between onset and hospitalization was 7.4 days(0 to 30 days)and the mean interval between hospitalization and diagnosis was 3.9 days(0 to 21 days). Intramural hematoma was identified in 21/29 patients using thin-slice T1-weighted MRI. CONCLUSION: Only 55% of patients with VAD demonstrate typical occipital/nuchal pain with sudden onset. Both MRI and MRA should be indicated for patients who complain of persistent, unilateral pain in the occipital/nuchal regions to prevent VAD being missed during diagnosis.

[Computational Fluid Dynamic Analysis of Intracranial Aneurysms Using Newly Developed Software:Can It Predict the Thin-Walled Region of Intracranial Aneurysm Preoperatively?]

OBJECT: Recent studies have shown that computational fluid dynamics(CFD)analysis is useful to evaluate flow dynamics of intracranial aneurysms. However, CFD analysis still requires high costs and substantial time even now. This study aimed to evaluate whether newly developed software can shorten the time for analysis and serve useful information during clipping surgery for intracranial aneurysms. METHODS: CFD analysis was performed in 55 unruptured cerebral aneurysms in 51 patients. The time required for analysis of each aneurysm was recorded. On the basis of CFD analysis, both pressure and wall shear stress(WSS)were calculated as the values at the systolic and diastolic phases, and also the mean value through one cardiac cycle. These data were compared between thin-wall points and other points within each aneurysm. RESULTS: The average time required for analysis was 3 hours, ranging from 1 to 15 hours. The CFD data could be referenced during surgery in each patient. The pressure in about 93% and 80% of the thin-wall points was higher than that at other points within each aneurysm in the systolic and diastolic phases, respectively. However, there was no significant correlation between WSS and wall thickness in each aneurysm. CONCLUSION: This study clearly shows that newly-developed software is simple and requires much shorter time for CFD analysis than previous methods. Higher pressure through the cardiac cycle may efficiently predict a thin-wall region within intracranial aneurysms, which strongly suggests that CFD analysis would be a valuable tool to determine the treatment strategy in patients with unruptured aneurysms.

Genomic organization of regions that regulate chicken glycine decarboxylase gene transcription: physiological and pathological implications.

Regions required for chicken glycine decarboxylase gene transcription were examined. A region between -82 and +22 (-82/+22) with motifs similar to binding sites for Sp1, NF-Y and CP2 was assigned to the proximal promoter active in both chicken hepatoma cell line, LMH, and hepatocytes in primary culture. In LMH cells, a genomic region, KX, between KpnI (-4155) and XbaI (-2113) sites changed promoter activity with the aid of four additional genomic regions termed upstream regulator regions for suppression (UpRS) and activation (UpRA) of transcription. Those precise segments are UpR1S (-376/-346), UpR1A (-345/-291), UpR2S (-137/-108) and UpR2A (-107/-83). Within KX, -4155/-3605 activates and -3604/-3367 suppresses the promoter. -3366/-3024 activates or suppresses the promoter, probably with different UpR counterparts. -2197/-2113 restores the actions of -3366/-3024. While in LMH cells, the upstream UpRs abrogate the functions of immediately downstream UpRs, UpR1S or UpR2S or both may be at least less active in hepatocytes than in LMH cells. Nuclear extracts from various chicken tissues and LMH cells had UpR2A binding proteins in different populations, suggesting that together with the UpRs, the segments in KX are involved in the regulation of cell type-specific transcription of this gene.

Embolization of ruptured aneurysms in the acute stage: experience at a single institute.

BACKGROUND: Recently, several reports have shown embolization to be more beneficial than surgical clipping for the treatment of ANs, because the former is less invasive. In our department, GDCE has been the first choice of treatment for ANs since 1977. In this work, we present our clinical results with GDCE and suggest this approach as an alternative treatment of ruptured ANs in the acute stage. METHODS: We treated 247 consecutive patients with acute-stage AN ruptures using GDC. To prevent symptomatic vasospasm, continuous lumbar drainage was performed before GDCE. If blood clots in the basal cisterns were dense on computerized tomography, TPA was administered through a lumbar spinal drainage tube. RESULTS: Of the 247 patients, 196 (79%) had excellent or good outcomes at 3 months after treatment. Symptomatic vasospasm occurred in 27 patients (13.9%), and 25 required chemical or mechanical angioplasty. Permanent morbidity due to vasospasm occurred in 8 patients (4.1%), and 3 patients died (1.5%). CONCLUSION: Subjects, perioperative treatment methods, and outcomes were assessed consecutively and prospectively in a single institution, making the results of this study particularly valuable. Although very long-term results of treating ANs with GDCE have yet to be obtained, our results suggest that embolization of ruptured ANs in the acute stage with GDC is a safe, feasible method of treatment.