Effect of Enteral Nutrition on In-hospital Infection and Hospital Expense in Stroke Patients: A Retrospective Assessment.

Infection is a common complication of stroke and is associated with unfavorable outcomes. Although nutritional intervention reduces the risk of postoperative infection, the impact of specific nutritional products remains unclear. From a hospital management perspective, we aimed to determine whether the provision of specific types of enteral nutrition in acute stroke patients affects infection control and hospital costs. In all, 45 acute hemorrhagic stroke patients receiving enteral nutrition in a single center (April 2017-March 2019) were retrospectively assessed. Patients were divided into two groups according to nutritional interventions: the 1.0-group with general nutrition (1.0 kcal/mL) (24 patients) and the 1.5+α-group with an initial high-protein, whey peptide-digested liquid diet (1.5 kcal/mL), followed by a highly fermentable fiber-containing liquid diet (1.5 kcal/mL initiated after 4 days) (21 patients). Changes in body mass index (BMI), duration of antibiotic use, incidence of postoperative infection, and medical cost were evaluated. Baseline patient characteristics were similar between groups. The mean BMI change was lower in the 1.5+α-group than in the 1.0-group, and the mean duration of antibiotic use throughout hospitalization was 12.8 and 18.3 days, respectively. Antibiotic use in the 1.5+α-group was lesser than that in Japanese patients from other hospitals. The incidence of postoperative infections was lower in the 1.5+α-group. Injection costs for the 1.5+α group (615 USD/patient) were lower than those for the 1.0-group. Enteral nutrition provided to acute stroke patients reduced the risk of hospital infection and medical costs.

High protein intake after subarachnoid hemorrhage improves oral intake and temporal muscle volume.

BACKGROUND & AIMS: Dysphagia is a common sequela following stroke. Patients with subarachnoid hemorrhage (SAH) often develop atrophy of the temporal muscle, but its clinical significance remains unclear. This study aimed to investigate whether temporal muscle volume (TMV) is related to subsequent oral intake in patients with SAH and evaluate the predictors of temporal muscle atrophy. METHODS: We performed a retrospective analysis of 60 SAH patients receiving enteral nutrition in the acute hospitalization phase at a single center between 2009 and 2019. The TMV was segmented automatically from computed tomography images and measured on admission and at week 2. Patients with a ≥20% TMV reduction were assigned to the atrophy group (n = 24) and those with a <20% TMV reduction were included in the maintenance group (n = 36). The patients' oral intake status was assessed at week 2 using the Food Intake LEVEL Scale (grade of 7-9 considered good ingestion), and the modified Rankin scale (mRS) was used at discharge (grade of 0-2 considered good prognosis). Additional data on age, sex, body mass index, severity of SAH, and protein intake were collected on day 4. RESULTS: The maintenance group had significantly better oral intake and mRS scores compared to the atrophy group. TMV maintenance significantly affected oral intake at week 2 and the mRS score at discharge. Multivariable logistic regression analysis revealed that protein intake on day 4 significantly influenced the maintenance of TMV. CONCLUSIONS: High protein nutrition in the acute stage of SAH contributes to temporal muscle maintenance and improves oral intake.

[A Case of Internal Jugular Arteriovenous Fistula Presenting as Lower Cranial Nerve Palsy].

INTRODUCTION: Although arteriovenous fistulas(AVFs)are typically located within the cranium, there are several published reports documenting rare cases of extracranial AVFs between the ascending pharyngeal artery(APA)and the internal jugular vein(IJV). Herein, we report the case of a patient with APA-IJV AVFs who presented with symptoms of lower cranial nerve palsy that was treated with transvenous embolization(TVE). CASE: A 53-year-old man presented with chief complaints of numbness in the left oral cavity and a temple headache. Magnetic resonance angiography showed an abnormal signal in the left jugular bulb. An AVF was suspected; digital subtraction angiography revealed the presence of a shunt from the jugular branch of the APA to the jugular bulb which was accompanied by regurgitation into the inferior petrosal sinus(IPS)and sigmoid sinus(SS). Numbness in the oral cavity was diagnosed as lower cranial nerve palsy associated with increased pressure within the jugular foramen. As the nature of the AVF(single or multi-hole)was uncertain, a therapeutic TVE was planned. Microcatheters were guided into the IPS and SS, and TVE was performed using a double-catheter technique. Regurgitation into the IPS resolved; embolization via the APA was not performed, and symptoms improved postoperatively. CONCLUSIONS: AVFs involving the APA and IJV are identified infrequently and there are only a few published case reports describing this vascular anomaly. Most reported cases were single-hole AVF and were treated with trans-arterial embolization via the APA. As noted in the present case, APA-IJV AVF can also be treated by TVE.

Status of In-Hospital Acute Ischemic Stroke Treated by Mechanical Thrombectomy.

Objective: To elucidate the current state of in-hospital acute ischemic stroke under the introduction of acute-phase mechanical thrombectomy. Methods: The study included 18 consecutive patients with in-hospital cerebral infarction who underwent thrombectomy between April 2014 and March 2020 at St. Marianna University School of Medicine Yokohama City Seibu Hospital. We analyzed the primary disease, department responsible for treatment, modified Rankin Scale (mRS) scores before onset and on discharge, status of onset, treatment course, and so on. Results: The mean age was 79.9 (66-93) years. There were nine females. The admission methods included scheduled admission in 5 patients and non-scheduled admission in 13 patients. The primary diseases consisted of malignant tumors in five patients and heart disease in four patients. The departments responsible for treatment consisted of the Department of Digestive Surgery for six patients and Department of Cardiology for three patients. The mRS score before admission was evaluated as 0-2 in 15 patients and 3-5 in 3 patients. The embolism was evaluated as cardiogenic in 14 patients. Antithrombotic therapy was discontinued before the onset of cerebral infarction in three patients. The mean interval from onset or last well known (LWK) until CT/MRI and puncture was 88.4 and 157.6 minutes. The median Alberta stroke program early CT score (ASPECTS; minimum-maximum) was 8 (2-10). Tissue plasminogen activator (t-PA) was administered to five patients. Concerning the degree of recanalization, the thrombolysis in cerebral infarction (TICI) grade was evaluated as 1 to 2a in 2 patients and 2b to 3 in 16. In the latter, the mean interval from onset or final onset-free confirmation until recanalization was 197.7 minutes. mRS score on discharge was evaluated as 0-2 in four patients, 3-5 in nine, and 6 in five patients. The mortality was related to a primary disease requiring admission in three patients. Conclusion: In-hospital onset cerebral infarction was markedly influenced by the primary disease requiring admission. Even when favorable recanalization was achieved, the number of patients with a favorable outcome was small.

[A Case of Primary Intrasellar Chondroid Chordoma].

OBJECTIVES: Intracranial chordomas are thought to arise from remnants of the notochord and usually occur at the parasellar region. We present a case of a primary intrasellar chondroid chordoma in a patient who was initially diagnosed with a pituitary adenoma. CASE: A 77-year-old woman had a history of two surgeries for a tumor in the sella turcica(17 months after the 1st surgery). On initial MRI, the intrasellar mass showed low signal intensity on T1WI, very high signal intensity on T2WI, and inhomogeneous enhancement. On bone reconstructive CT, the sellar floor was thin, and no abnormalities were observed at the top of the clivus. Transsphenoidal surgery was performed. The pathological diagnosis was pituitary adenoma in both cases. Seventy-two months after the 1st(31 months after the 2nd)surgery, she developed right-sided oculomotor and abducent nerve palsies again. Since recurrence occurred during the relatively short period, the surgical specimens obtained from the 1st and 2nd surgeries were reexamined. Reexamination of the previously obtained specimen demonstrated areas of chondroid tissue that were embedded in a mucoid stroma and tumor cells that were composed of round or pleomorphic nuclei with vacuolated cytoplasm(physaliphorus cells)that were compatible with chondroid chordoma. The third surgery was performed. Postoperatively, her symptoms improved, and cyber knife therapy was administered for the residual part of the tumor. CONCLUSIONS: Although intrasellar chondroid chordomas are extremely rare, they should be considered in the differential diagnosis of tumors located in the sella turcica.

[A Case of Primary Extradural Meningioma Located at the High Convexity:A Case Report and Review of the Literature].

OBJECTIVES: Primary meningiomas arising outside the intracranial component are rather rare and have been termed primary extradural meningiomas(PEMs). We present a case of an intraosseous-type PEM occurring at a high convexity location and discuss the clinical characteristics of PEMs. CASE: An 80-year-old woman presented with a soft and painless subcutaneous mass of approximately 10 cm in diameter in the right parietal region, which had appeared 1 year previously. Mild cognitive dysfunction and left hemiparesis were observed upon admission. A skull radiograph and a bone window computed tomography scan revealed an osteolytic lesion at the above-mentioned site. Magnetic resonance imaging indicated that the mass was inhomogeneously enhanced and seemed to extend through the skull defect both intra- and extra-cranially. The preoperative diagnosis was a metastatic skull bone tumor due to the patient's history of breast cancer. During surgery, the tumor was found to be solid and had expanded through both the inner and outer tables of the skull, destroyed the inner table at one location, and perforated into the subdural space via the thinned, but not infiltrated, dura mater. The tumor was removed along with a wide margin of surrounding healthy bone and a cranioplasty was performed using a titanium plate. The histopathological diagnosis was atypical meningioma(World Health Organization grade II). Postoperatively, no adjuvant therapies(radiation and/or chemotherapy)were administered and the patient was reported to be well at 8 months post-surgery with no evidence of tumor recurrence. CONCLUSIONS: Although PEMs are rather rare, clinicians should consider the differential diagnosis of osteolytic skull vault tumors.

[De Novo Cavernous Angioma Secondary to a Developmental Venous Anomaly:A Case Report and Review of the Literature].

OBJECTIVE: Previously, cavernous angiomas(CAs)have been thought to be only congenital in origin. Recently, however, a few cases of de novo CAs have been reported in the literature. We present a case of a de novo CA and discuss the etiology of the newly appeared CA. CASE REPORT: A 29-year-old man was presented to a local clinic because of hypersomnia. MRI demonstrated a heterogeneous mass peripherally located, which was in contact with a developmental venous anomaly(DVA)at the left thalamus. Six years before the presentation, he visited the same clinic because of faintness, and MRI results indicated no abnormality except for the DVA. Three weeks later, he suddenly experienced difficulty in speech, and the MRI revealed an increase in the size of the mass. Subsequently, he was admitted at our institution, and neurological examination revealed aphasia and right hemiparesis. A left carotid angiogram on venous phase showed a narrowing of the DVA, which was seen as it entered the internal cerebral vein. The diagnosis of a de novo CA was made. The mass was completely resected through the transcallosal transventricular approach to avoid injuring the DVA. The DVA could not be found during surgery. The pathological diagnosis was in line with the findings of CA. Postoperatively, the patient continued having difficulty in speech and was transferred to another institution for speech rehabilitation. CONCLUSIONS: Although the association of CA and DVA has been described with increasing frequencies recently, the etiology of de novo CA in the case of this association has been a matter of debate. In the present case, it was speculated that a narrowing of the DVA resulted in increased venous pressure and caused the development of de novo CA.

[Dural cavernous angioma:a case report and review of the literature].

Here, we report a case of dural cavernous angioma. A 54-year-old man presented with headache in his right frontal area for the previous few weeks. Computed tomography (CT) and magnetic resonance imaging revealed a well-demarcated extramedullary mass, 3 x 2.5cm in size, within the subdural space at the right frontal region. The mass was not enhanced on a contrast-enhanced CT scan, and heterogeneously enhanced after administration of Gd-DTPA on magnetic resonance images. Cerebral angiography revealed an avascular mass. Right frontal craniotomy was performed. On surgery, the mass was found to be mainly extramedullar, and partially intramedullar. No adhesion between the mass and the overlying dura was observed. It was removed in an en bloc fashion. The pathological diagnosis was cavernous angioma. The patient's headache was resolved soon after surgery. Cavernous angiomas are usually intramedullar in the subcortical white matter of the cerebral hemispheres;extramedullary cavernous angiomas are rare. Extramedullary dural cavernous angiomas located in the subdural space at the cerebral convexity are extremely rare. They usually present with headache or mass signs, and resemble meningioma radiologically. During surgery they are easily resected with minimal blood loss. Dural cavernous angiomas should be considered in the differential diagnosis of intradural extramedullary mass at the cerebral convexity.

Cerebral hyperperfusion syndrome following the excision of a mycotic aneurysm with superficial temporal artery-to-middle cerebral artery bypass: case report.

The authors report a rare case of cerebral hyperperfusion syndrome (HPS) following the excision of a mycotic aneurysm with superficial temporal artery-to-middle cerebral artery (STA-MCA) bypass. A 74-year-old woman with infective endocarditis presented with progressive cerebral infarction and subarachnoid hemorrhage due to a mycotic aneurysm, which was excised with a STA-MCA bypass. Postoperatively, the patient developed HPS that was considered to be exacerbated by a previous ischemic event. Therefore, cerebral hemodynamics should be evaluated before bypass surgery to prevent subsequent hyperperfusion.

A case of intracerebral metastasis in osteosarcoma without active pulmonary metastasis.

Intracerebral metastasis in osteosarcoma is extremely rare. A 14-year-old girl who had previously been operated upon for osteosarcoma of the femur presented with seizures and left hemiparesis. A right parietal lesion with calcification and brain oedema was found. After resection of the mass, pathology revealed an osteosarcoma metastasis.

Intracranial foreign body granuloma caused by dural tenting suture.

Our patient presented with a mass lesion mimicking a meningioma. The mass was resected, but pathological examination confirmed a foreign body granuloma, which was caused by silk fibres used as tenting sutures 8 years previously. Herein, we describe the case and review the neurosurgical literature on intracranial foreign body granulomas.

[A case of serous surface papillary carcinoma of the peritoneum metastatic to the brain].

A case of brain metastasis from peritoneal serous surface papillary carcinoma (SSPC) was reported. This 68-year-old woman was admitted to our department because of decreased consciousness level for the last few days. Her medical past history revealed breast cancer and SSPC of the peritoneum at the age of 64. On admission she was comatose and irritable. Serum and urine examination revealed the syndrome of inappropriate secretion of antidiuretic hormone that was treated with strict restriction of water intake. MRI of the brain demonstrated a nonspecific mass in the subcortical area of the right superior parietal lobule. The mass was successfully removed in en bloc fashion. Pathological diagnosis was SSPC that was compatible with the previous diagnosis obtained from the peritoneum four years previously. Although the patient received whole brain radiation therapy postoperatively, her condition deteriorated rapidly. She died four months after brain surgery. SSPC of the peritoneum is a rare malignant tumor that is defined as a primary tumor histologically indistinguishable from serous carcinoma of the ovary, diffusely involving the peritoneal surface but sparing or only superficially invading the ovaries. Because of the prolongation of survival resulting from advanced chemotherapy for SSPC of the peritoneum, more patients live long enough to develop brain metastasis. Therefore, SSPC of the peritoneum should be kept in mind in the differential diagnosis of a primary site for brain metastasis.

Supratentorial high convexity intradural extramedullary cavernous angioma: case report.

A 59-year-old man presented with a 2-month history of numbness in the lower left side of the face and upper left extremity. Axial T(1)-weighted magnetic resonance imaging showed a wedge-shaped mass measuring 3 x 2.5 cm in the right frontoparietal high convexity area that was heterogeneously enhanced after administration of gadolinium-diethylenetriaminepenta-acetic acid. Right frontoparietal craniotomy was performed and a bluish soft mass was found under the arachnoid membrane. The mass could be dissected free from the arachnoid membrane and the brain surface. Histological examination revealed the typical findings of cavernous angioma. Cavernous angioma should be considered in the differential diagnosis of supratentorial high convexity intradural extramedullary tumor, especially appearing as a heterogeneously enhanced mass adjacent to the brain parenchyma causing mass effect.

[A case of cavernous angioma presenting as migrainous attack].

A 40-year-old man presented with progressive visual impairment accompanied by throbbing headache. First he had throbbing headache in the left temporal region. At the same time he noticed a blind spot in the upper right quadrant. This blind spot gradually became enlarged. Since the patient had throbbing headache accompanied by right homonymous hemianopsia, his illness was initially diagnosed as migraine. Sumatriptan was prescribed. However, thereafter his headache still continued. He described his seeing of some lights like neon signs. Magnetic resonance imaging revealed a typical feature of cavernous angioma (CA) at the left temporooccipital lobe and electroencephalogram showed frequent spike waves at the same region. Because of progressive deterioration of his condition despite the treatment with antiepileptics, left temporal craniotomy was performed. The CA was removed with a small amount of surrounding gliotic tissue using an intraoperative cortical EEG recording. Postoperatively, his visual symptoms and headache disappeared. Although migraine is one of the most frequently encountered symptoms in daily practice, differentiation of migraine from seizure - associated headache is extremely difficult, because both conditions may manifest similar features of visual impairment with throbbing headache. When clinicians see a patient presenting with throbbing headache accompanied by visual symptoms, CAs or other space occupying lesions, should be kept in mind of a differential diagnosis of migrainous attacks.

[A case of ruptured internal carotid artery "kissing aneurysms": case report and review of the literature].

OBJECTIVE: A rare case of ruptured kissing aneurysms on the right internal carotid-posterior communicating artery (ICPCA) and -anterior choroidal artery (ICAchA) is reported. CASE: A 47-year-old female was transferred to our hospital because of subarachnoid hemorrhage (SAH). Cerebral angiography revealed two aneurysms on the right ICPCA and ICAchA. Right frontotemporal craniotomy was performed to obliterate them on the day of admission. Despite the presence of angiographical cleavage, these two aneurysms were attached to each other tightly, and it was extremely difficult to dissect the space between them and premature rupture occurred. A Sugita long straight clip was inserted parallel to internal carotid artery to obliterate the body of ICAchA aneurysm and the neck of ICPCA aneurysm. Another straight clip was applied to the neck of the former aneurysm. Both PCA and AchA could be secured successfully. Postoperatively, although she developed symptomatic vasospasm on the 10th day, she discharged without any neurological deficits 40 days later. CONCLUSIONS: Because of the difficulty in dissection of aneurysms, the operation for kissing aneurysms has been recognized as hazardous and challenging since Jefferson. We emphasize that a clipping technique described above should be kept in mind as a safe value, though meticulous dissection of each aneurysmal neck followed by independent neck clipping is reasonable.

[Unilateral exophthalmos caused by a prolactin producing ectopic pituitary adenoma: case report].

OBJECTIVE: We report a case of a patient with a prolactin (PRL) producing ectopic pituitary adenoma presenting a unilateral exophthalmos. CASE: This 70-year-old woman presented an ophthalmologist with progressive left-sided exophthalmos over the previous 2 months. Bone window CT scan revealed extensive bony destructions of the skull base including the clivus, sphenoid sinus and medial aspect of the middle cranial fossa. Gd-DTPA MRI revealed an abnormal enhancement lesion in the sphenoid sinus, but no abnormal enhancement was seen in the sella turcica. Since these findings suggested malignant tumors of the cranial base, several biopsies through the transnasal route were carried out to confirm the diagnosis. This procedure caused the complication of cerebrospinal fluid (CSF) leakage. Because the biopsy specimen revealed a PRL producing adenoma (serum PRL-level 645.7 ng/ml), the patient was admitted to our department. On admission neurological examination showed an exophthalmos with external ocular movement disorders and disturbance of visual acuity on the left side. She underwent transsphenoidal surgery to remove the tumor and to reconstruct the sphenoid sinus and the sellar floor. Surgical exploration revealed a yellowish and soft tumor underneath the normal mucous membrane in the sphenoid sinus. The sellar floor was destructed extensively, but the dura mater of the pituitary fossa was intact except for a small pin-hole which was thought to be produced during the several biopsy procedures. No surgical procedure was applied to the intrasellar region. The sphenoid sinus was packed with a piece of fascia and fat applied with the aid of fibrin glue to prevent CSF leakage. RESULT: The patient followed a satisfactory postoperative course. Her visual acuity disturbance and exophthalmos disappeared one year after surgery. Postoperative serum PRL level remained high (66.9 ng/ml), but, subsequently, was normalized (9.5 ng/ml) with a bromocriptine therapy (15 mg daily). CONCLUSION: As far as we are aware, this is the first case report of an ectopic pituitary adenoma causing unilateral exophthalmos. Although it is extremely rare, pituitary adenomas should be kept in mind in a differential diagnosis of exophthalmos.

Delayed treatment with nicotinamide (vitamin B3) reduces the infarct volume following focal cerebral ischemia in spontaneously hypertensive rats, diabetic and non-diabetic Fischer 344 rats.

Since hypertension and/or hyperglycemia are risk factors for stroke, we examined whether the putative neuroprotectant, nicotinamide (NAm), could protect spontaneously hypertensive rats (SHR) or diabetic Fischer 344 rats against focal cerebral ischemia using a model of permanent middle cerebral artery occlusion (MCAo). Intravenous NAm given 2 h after MCAo significantly reduced the infarct volume of SHR (750 mg/kg, 31%, P<0.01) and diabetic (500 mg/kg, 56%, P<0.01) as well as non-diabetic (500 mg/kg, 73%, P<0.01) Fischer 344 rats when compared with saline-injected controls. Thus delayed treatment with NAm protected hypertensive and hyperglycemic rats against a robust model of stroke.