Diffusion MRI Fiber Tractography and Benzodiazepine SPECT Imaging for Assessing Neural Damage to the Language Centers in an Elderly Patient after Successful Reperfusion Therapy.

BACKGROUND: Intravenous thrombolysis and mechanical thrombectomy are the first-line reperfusion therapies for acute ischemic stroke. Here, we describe the utility of diffusion magnetic resonance imaging (MRI) fiber tractography and 123I-iomazenil benzodiazepine receptor single-photon emission computed tomography to estimate the prognosis of post-stroke aphasia after successful reperfusion therapy. CASE REPORT: An 81-year-old man was admitted to the hospital approximately 3.5 h after the onset of symptoms, including decreased consciousness, right hemiparesis, and aphasia. An MRI revealed acute cerebral infarction due to M1 segment occlusion. Intravenous alteplase thrombolysis followed by endovascular thrombectomy resulted in recanalization of the left middle cerebral artery territory. A subsequent MRI showed no new ischemic or hemorrhagic lesions. Although the patient's motor hemiparesis gradually recovered, motor aphasia persisted. Diffusion MRI fiber tractography performed 2 weeks after admission revealed partial injury to the left arcuate fasciculus, indicated by lower fractional anisotropy values than on the contralateral side. A decreased benzodiazepine receptor density was also detected in the left perisylvian and temporoparietal cortices. The patient showed no clear signs of further improvement in the chronic stage post-stroke and was discharged to a nursing home after 3 months. CONCLUSIONS: The application of functional neuroimaging techniques to assess neuronal damage to the primary brain regions 2 weeks after reperfusion therapy for large-vessel occlusion may allow for an accurate prognosis of post-stroke aphasia. This may have a direct clinical implication for navigating subacute-to-chronic phases of rehabilitative care.

Gelation upon the Mixing of Amphiphilic Graft and Triblock Copolymers Containing Enantiomeric Polylactide Segments through Stereocomplex Formation.

Biodegradable injectable polymer (IP) systems that form hydrogels in situ when injected into the body have considerable potential as medical materials. In this paper, we report a new two-solution mixed biodegradable IP system that utilizes the stereocomplex (SC) formation of poly(l-lactide) (PLLA) and poly(d-lactide) (PDLA). We synthesized triblock copolymers of PLLA and poly(ethylene glycol), PLLA-b-PEG-b-PLLA (tri-L), and a graft copolymer of dextran (Dex) attached to a PDLA-b-PEG diblock copolymer, Dex-g-(PDLA-b-PEG) (gb-D). We found that a hydrogel can be obtained by mixing gb-D solution and tri-L solution via SC formation. Although it is already known that graft copolymers attached to enantiomeric PLLA and PDLA chains can form an SC hydrogel upon mixing, we revealed that hydrogels can also be formed by a combination of graft and triblock copolymers. In this system (graft vs. triblock), the gelation time was shorter, within 1 min, and the physical strength of the resulting hydrogel (G' > 100 Pa) was higher than when graft copolymers were mixed. Triblock copolymers form micelles (16 nm in diameter) in aqueous solutions and hydrophobic drugs can be easily encapsulated in micelles. In contrast, graft copolymers have the advantage that their molecular weight can be set high, contributing to improved mechanical strength of the obtained hydrogel. Various biologically active polymers can be used as the main chains of graft copolymers, and chemical modification using the remaining functional side chain groups is also easy. Therefore, the developed mixing system with a graft vs. triblock combination can be applied to medical materials as a highly convenient, physically cross-linked IP system.

A case of anti-SAE1/2 antibody-positive dermatomyositis with extensive panniculitis: A possible cutaneous manifestation of treatment resistance.

Dermatomyositis constitutes a heterogeneous group of autoimmune inflammatory conditions with a wide variety of clinical outcomes. The symptomatic heterogeneity carries skin, muscle, and joint manifestations; pulmonary and cardiac involvements; and concomitant malignancy. Any of these symptoms often appear at different combinations and time courses, thus posing difficulty in early diagnosis and appropriate treatment choice. Recent progress in laboratory investigations explored the identification of several myositis-specific autoantibodies (MSAs) and myositis-associated autoantibodies, allowing precise characterization for a clinical perspective of the disease. MSAs can be detectable in approximately 80% of patients with whole dermatomyositis, some of which closely reflect unique clinical features in the particular disease subset(s), including the distribution and severity of organ involvement, treatment response, and prognosis. However, only limited evidence has been available in dermatomyositis-associated panniculitis, mostly that in anti- melanoma differentiation-associated protein 5 antibody-positive disease. We present a rare case of a patients with dermatomyositis with extensive panniculitis on the trunk whose serum IgG autoantibodies reacted with both subunits of small ubiquitin-like modifier activating enzymes (SAEs), SAE1 and SAE2. The onset of panniculitis coincided with increased disease activity, including disease-related skin manifestations, fever, dysphagia, and muscle weakness in the extremities. These symptoms responded well to a high dose of systemic steroid, but even upon receiving a high-dose intravenous immunoglobulin, the panniculitic lesions and pruritic erythema flared with tapering of steroid dose, further requiring tacrolimus and mycophenolate mofetil to achieve disease remission. To our knowledge, this is the third reported case of anti-SAE autoantibody-positive dermatomyositis with panniculitis. We aim to extend the understanding of the current limitation and further perspective in the clinical management of the extremely rare skin manifestation associated with dermatomyositis.

[A Case of Penile Calciphylaxis in a Hemodialysis Patient].

In the present case of a 56-year-old male, hemodialysis was introduced from December 20XX-2 due to chronic renal failure caused by diabetic nephropathy. In February 20XX, a glans penis ulcer was observed. It gradually expanded. Angiography conducted in April revealed complete occlusion of the left internal pudendal artery and poor visualization of the bilateral penile arteries. Given the high risk of obstruction, endovascular treatment was not conducted. The glans penis ulcer continued to expand, and maintenance dialysis became difficult due to intractable pain. Opioids were introduced, but the pain could not be controlled. In May 20XX, the patient was referred to our department for surgical treatment, and partial penile resection was performed. The patient was diagnosed with penile calciphylaxis based on clinical findings and pathological diagnosis. After the surgery, the pain subsided considerably, and the patient is being followed on an out-patient basis.

What are the kinematic characteristics of the world champion couple in competitive ballroom dance during the waltz's spin movement?

To evaluate competitive ballroom dancing, one of the official events of the World Games, spin movements used by advanced dancers who ranked high in actual competition may be employed. The purpose of this study was to investigate the kinematic characteristics of spin movements in competitive ballroom dancing performed by world champion couples, especially holding posture and lower limb movements. A champion couple and 13 national-level competitive ballroom dancers as the control group participated in this study. An inertial measurement unit (IMU) system (MVN Link; Xsens, Netherlands) consisting of 17 IMUs, attached to feet, shanks, thighs, pelvis, sternum, head, upper arms, forearms, and hands of the dancers, was used to obtain three-dimensional kinematic data at 240 Hz. The overall trend was that the actual and normalized stride lengths of the champion male and female dancers tended to be longer than those of the male and female dancers in the control group. Further, large differences were observed in the pelvic and rib cage segments movements, and the relative angle of the rib cage segment to the pelvic segment. The champion male dancer started to move from the pelvic segment, whereas the champion female dancer and the national-level top male and female dancers started to move from the rib cage segment. During the spin movement, the champion male dancer was in a position where the rib cage segment was rotated to the left with respect to the pelvic segment, whereas the other dancers were in a position where the rib cage segment was rotated to the right. Although limited to technical aspects, these dance kinematic characteristics of the world champion couples and their differences from those of the control group dancers, will be helpful to competitive ballroom dancers and coaches in their daily practice.

A Case Report of Contrast-Induced Encephalopathy after Repeated Percutaneous Transluminal Angioplasty for Acute Middle Cerebral Artery Occlusion.

Objective: We report a case of contrast-induced encephalopathy (CIE) after repeated percutaneous transluminal angioplasty (PTA) for acute middle cerebral artery (MCA) occlusion. Case Presentation: An 88-year-old woman with left hemiparesis was transferred to our hospital by ambulance. MRI revealed acute MCA M1 occlusion. We performed intravenous tissue plasminogen activator therapy and PTA for right MCA occlusion, leading to complete recanalization and improvement in hemiparalysis. After approximately one week, restenosis of right MCA developed and PTA was performed again on day 11. However, her left hemiparesis exacerbated shortly thereafter. CT demonstrated leakage of contrast medium, and an extensive high-intensity area (HIA) on the white matter in the right cerebral hemisphere was noted on MRI FLAIR. The HIA on MRI and neurological deficits gradually improved after conservative treatment, but diffuse atrophy of the right cerebral hemisphere occurred and higher brain dysfunction remained. Conclusion: Repeated ischemia and reperfusion, and the frequent use of contrast media were considered the causes of CIE.

Acute Myocardial Infarction Due to Coronary Occlusion Caused by a Metastatic Cardiac Tumor Arising from Squamous Cell Lung Cancer: An Evaluation with Three-dimensional Transthoracic Echocardiography.

A 60-year-old man developed acute myocardial infarction from the total occlusion of the right coronary artery via metastatic squamous lung cancer and was treated with percutaneous coronary intervention (PCI). Computed tomography and transthoracic echocardiography (TTE) revealed a metastatic tumor, and three-dimensional TTE was useful for determining the size and location of the tumor in relation to the coronary artery. Six months after PCI, the patient died, and an autopsy confirmed extensive metastasis to the heart and nearby vessels as detected by three-dimensional TTE. Although rare, lung cancer metastasis to the heart may directly occlude the coronary artery.

Role of magnetic resonance vessel wall imaging in detecting and managing ruptured aneurysms among multiple intracranial aneurysms.

BACKGROUND: Wall enhancement of intracranial saccular aneurysms in high-resolution magnetic resonance vessel wall imaging (MR-VWI) might indicate a ruptured aneurysm. Therefore, this study aimed to determine the diagnostic ability of wall enhancement to detect the ruptured aneurysms among multiple aneurysms. METHODS: Patients with subarachnoid hemorrhage (SAH) and multiple intracranial aneurysms who underwent MR-VWI before craniotomy and clipping were included in the study. Three-dimensional T1-weighted fast spin-echo sequences were obtained before and after gadolinium injection. Aneurysm rupture was estimated based on the subarachnoid clot distribution, aneurysmal contours, and MR-VWI findings. We selectively performed surgical clipping and confirmed the rupture site intraoperatively. RESULTS: Thirteen patients with SAH with 13 ruptured and 17 unruptured aneurysms were treated at out facility. The accuracy rate of rupture site diagnosis using MR-VWI was 69.2% (9/13 cases). Each unruptured aneurysm was equally or more strongly enhanced in the other four cases than the ruptured aneurysms. In three of the four unruptured aneurysms with positive MR-VWI findings, atherosclerosis of the aneurysmal wall was observed during simultaneous or elective clipping surgery. Further, clipping surgery was performed without intraoperative rupture in two cases with the help of MR-VWI findings. CONCLUSION: Correct diagnosis of the rupture site using MR-VWI alone was unreliable due to false positives caused by the wall enhancement of unruptured aneurysms with atherosclerosis. Therefore, ruptured aneurysms should be detected using more information in addition to MR-VWI images. MR-VWI may be advantageous to determine surgical strategies when managing patients with SAH and multiple aneurysms.

A case of an atypical teratoid/rhabdoid tumor with distinctive histology in the pineal region in an adult patient.

A 31-year-old man suffered from headaches and presented at a hospital after the symptom worsened. Obstructive hydrocephalus and a pineal tumor were identified, and he was transferred to our hospital for further investigation and treatment. Cranial computed tomography revealed a hypodense mass lesion on the right of the pineal region, and calcifications and enlargement of the lateral and third cerebral ventricles were also evident. Blood tests were negative for all tumor markers. Laparoscopic biopsy and third-ventricle fenestration were performed that day as an emergency surgery to treat the obstructive hydrocephalus. Postoperative cranial magnetic resonance imaging revealed a solid tumor that was hypointense on T1-weighted imaging, hyperintense on T2-weighted imaging, and heterogeneously enhanced by Gd. Subsequently, the tumor increased in size, and craniotomy and tumorectomy were performed. Histologically, the tumor proliferated as round or short spindle-shaped cells in a myxoid matrix, forming arrays that surrounded the blood vessels. As a few cells with eosinophilic cytoplasm were also present and immunostaining for INI-1 was negative, the patient was diagnosed with atypical teratoid/rhabdoid tumor (AT/RT). AT/RT of the pineal region in adults is rare, and herein, we report the morphological characteristics of this case and reviewed the relevant literature.

Long-standing refractory hidradenitis suppurativa responded to a brodalumab monotherapy in a patient with psoriasis: A possible involvement of Th17 across the spectrum of both diseases.

Hidradenitis suppurativa (HS), also known as acne inversa, is a chronic inflammatory skin disease mainly affecting apocrine gland-rich areas of the body with painful nodules, persisted abscess, sinus tracts, and scarring. The etiopathology of HS remains unclearly understood, but the disease is considered as a polygenic autoinflammation condition originating from follicular hyperkeratosis and occlusion. Recent advances concerning the substantial roles of tumor necrosis factor (TNF)-α, interleukin (IL)-1ß, IL-17, and IL-23 have accelerated in developing a repertoire of therapeutic biologics in HS. Currently five biologics antagonistic for these different cytokines, adalimumab, anakinra, etanercept, infliximab, and ustekinumab, have been explored in the treatment setting of HS; however, only limited evidence is available for the therapeutic advantage of IL-17 pathway blockade. We present a 47-year-old Japanese man who had a long-standing, debilitating HS complicated with psoriasis, both of which were refractory to a series of the standard treatment. Not only psoriatic skin but also HS lesions responded dramatically to brodalumab, an IL-17 receptor antagonist, accompanied with decrease of validated assessments, namely the Hurley's staging classification and modified Sartorius score. Brodalumab was well tolerated with rapid improvement and no adverse reaction, and finally gave a satisfactory maintenance of disease remission. To our best knowledge, this is the first successful use of anti-IL-17 receptor antibody in a Japanese case with coexistence of HS and psoriasis. We also discuss extending understanding of the potential benefit and current limitation of brodalumab in the treatment of HS.

A Case of Acute Ischemic Stroke Treated with Endovascular Treatment for Tandem Occlusion of the Common Carotid Artery and Internal Carotid Artery Terminal Portion Related to Takayasu Arteritis.

Objective: This report presents a case of mechanical thrombectomy for left internal carotid artery (ICA) terminal portion occlusion performed by left common carotid artery recanalization during hospitalization after diagnosing bilateral common carotid artery occlusion due to Takayasu arteritis. Case Presentation: A 25-year-old woman with fever and cervix pain a few months ago visited our department after repeated transient aphasic attacks. Magnetic resonance imaging (MRI) demonstrated diffuse infarction in the left middle cerebral artery (MCA) area, and she was diagnosed with Takayasu arteritis due to bilateral common carotid artery occlusion and left subclavian artery stenosis. On the 20th day of hospitalization, the terminal portion of the left ICA was occluded and thrombectomy was performed after balloon dilation of the left common carotid artery. Lastly, left common carotid artery stenting was performed. Aphasia and sensory disturbance remained, but she was transferred to a rehabilitation hospital with a modified Rankin Scale (mRS) of 2 on the 65th day of hospitalization. Antithrombotic and immunosuppressive therapy were performed, and restenosis did not develop. Conclusion: Angioplasty and stenting of common carotid artery occlusion can be effective treatments in thrombectomy for intracranial occlusion due to Takayasu disease.

Partnering Effects on Joint Motion Range and Step Length in the Competitive Waltz Dancers.

Competitive dance, also known as DanceSport, is one of the official sports of the World Games. The most salient characteristic of ballroom dance is the closed-hold position, during which the upper body segments of partner-dancers are linked. This study aimed to investigate partnering effects on joint motion ranges of the lower extremity and step lengths during the waltz in 13 national level competitive dance couples and a world champion couple. A Xsens MVN system was used to record movement at 240 Hz. Solo and pair conditions were examined. Compared with the highly skilled couples, the world champion couple demonstrated superior dance skills for generating the first step length in the pair condition of the waltz. This was particularly evident in the step length and joint motion range of the champion female dancer.

[Unilateral Transcranial Endoscopic Surgical Removal for Large Intraventricular Tumor Assisted by Contralateral Neuroendoscope].

We report a case of a patient with large intraventricular tumor treated with craniotomy assisted by a neuroendoscope. A 25-year-old man, who had headache and nausea for several months, was transferred to our hospital with the diagnosis of an intraventricular tumor. Because of intracranial hypertension and hydrocephalus, we first performed a biopsy and bilateral intraventricular drainage using a neuroendoscope. Since the pathological finding indicated central neurocytoma, we secondarily attempted tumor removal. The main location of the tumor was the left lateral ventricle, protruding into the third ventricle and contralateral lateral ventricle. The operation was performed mainly under microscopic visualization through left-sided craniotomy, and the total excision was accomplished using a neuroendoscope through the right lateral ventricle. In order to accomplish the optimal removal of an intraventricular tumor, endoscope-assisted microsurgery should be considered a surgical strategy.

[Pathological Complete Response in a Case of Advanced Gastric Cancer with Para-Aortic Lymph Nodes Metastasis Treated by Preoperative Chemotherapy with S-1 and Oxaliplatin(SOX Therapy)].

The patient was a 73-year-old man, diagnosed as advanced gastric cancer with para-aortic lymph nodes(PAN)metastasis. He was treated by 3 courses of neoadjuvant chemotherapy(NAC)with S-1 and oxaliplatin(SOX therapy). CT showed significant reduction of both primary tumor and metastatic lymph nodes. We performed distal gastrectomy with D2 plus PAN dissection. The histopathological findings showed no residual viable tumor cell. The pathological effect of chemotherapy was judged Grade 3(pCR)in both primary tumor and dissected lymph nodes. He is alive without recurrence 21 months after surgery.

[A Case of Pulmonary Carcinoid That Has Regressed Spontaneously].

A 65-year-old woman who had diabetes mellitus was referred to the Department of Diabetes Internal Medicine of our hospital in June 201X due to disease progression. Chest radiography revealed an abnormal shadow, and computed tomography( CT)showed a 2 cm nodular shadow in the right S10. Lung cancer was suspected because of increased serum progastrin- releasing peptide(ProGRP)level and smoking history. She was referred to our department and was diagnosed with carcinoid on transbronchial biopsy. After 1 month, CT demonstrated regression of the carcinoid and improved serum ProGRP level. After more than 1 month, the carcinoid size did not change, and serum ProGRP level slightly increased. We expected that it would be difficult for the carcinoid to regress. After glycemic control was improved, the patient underwent right lower lobectomy via video-assisted thoracoscopy. In the resected specimen, the border of carcinoid was clear. She was diagnosed with a typical carcinoid. The carcinoid was not accompanied by inflammation or necrotic tissue. A carcinoid is a low-grade malignant tumor and does not usually regress spontaneously. However, in this case, it regressed spontaneously.

OCCUPATIONAL RADIATION EXPOSURE OF THE EYE IN NEUROVASCULAR INTERVENTIONAL PHYSICIAN.

Neurovascular interventional radiology (neuro-IR) procedures tend to require an extended fluoroscopic exposure time and repeated digital subtraction angiography. To evaluate the actual measurement of eye lens dose using a direct eye dosemeter in neuro-IR physicians is important. Direct dosimetry using the DOSIRIS™ (IRSN, France) [3 mm dose equivalent, Hp(3)] was performed on 86 cases. Additionally, a neck personal dosemeter (glass badge) [0.07 mm dose equivalent, Hp(0.07)] was worn outside the protective apron to the left of the neck. The average doses per case of neuro-IR physicians were 0.04 mSv/case and 0.02 mSv/case, outside and inside the radiation protection glasses, respectively. The protective effect of radiation protection glasses was approximately 60%. The physician eye lens dose tended to be overestimated by the neck glass badge measurements. A correct evaluation of the lens dose [Hp(3)] using an eye dosemeter such as DOSIRIS™ is needed for neuro-IR physicians.

The Significance of Lactate and Lipid Peaks for Predicting Primary Neuroepithelial Tumor Grade with Proton MR Spectroscopy.

PURPOSE: 1H-MRS is a non-invasive technique used to assess the metabolic activity of brain tumors. The technique is useful for the preoperative prediction of tumor grade, which is important for treatment planning and accurate prognosis. We used 1H-MRS to study the lactate peak, which appears in various conditions, including hyperglycemia, ischemia, and hypoxia and lipid peak, which is associated with necrotic cells. The purpose of this study was to retrospectively examine the frequency and significance of lactate and lipid peaks in relation to brain tumor grade. MATERIALS AND METHODS: Fifty-five patients diagnosed with neuroepithelial tumors of Grades I (3 cases), II (11 cases), III (15 cases), and IV (26 cases) were enrolled. Biopsies were excluded. Single voxel (TE = 144 ms) point resolved 1H-MRS spectroscopy sequences were retrospectively analyzed. An inverted doublet peak at 1.3 ppm was defined as lactate, a negative and positive peak was defined as combined lactate and lipid, and a clear upward peak was defined as lipid. RESULTS: Lactate peaks were detected in all grades of brain tumors and were least common in Grade II tumors (9.1%). The frequency of combined lactate-lipid peaks was 0% (Grades I and II), 8.3% (Grade III), and 44% (Grade IV). Grade IV tumors were significantly different to the other grades. There were three cases with a lipid peak. All were glioblastoma. CONCLUSIONS: The presence of a lac peak may be useful to largely rule out the Grade II tumors, and allow the subsequent differentiation of Grade I tumors from Grade III or IV tumors by conventional imaging. The presence of a lipid peak may be associated with Grade IV tumors.

Comparison of the low-density lipoprotein cholesterol target value and the preventive effect of statins in elderly patients and younger patients.

OBJECTIVE: To assess whether the low-density lipoprotein cholesterol (LDL-C) target value and preventive effect of statins are different between elderly and younger patients. METHODS: We investigated 304 patients with previous percutaneous coronary intervention who underwent coronary angiography from January 2007 to December 2016 for examination of recurrent ischemia beyond the early restenosis. Patients were classified into two groups: age ≥ 75 years (elderly group: n = 140) and < 75 years (younger group: n = 164). Relationships between the achieved LDL-C level, incidence of late coronary events, and the effectiveness of statins were evaluated. RESULTS: During follow-up, 179 patients underwent late coronary revascularization. Recurrent ischemia presenting as acute coronary syndrome (ACS) occurred in 83 cases. Kaplan-Meier curve analysis revealed that in the younger group, recurrent ACS was significantly lower in patients with LDL-C < 70 mg/dL than in those with LDL-C ranging from 70 to < 100 mg/dL (P = 0.035); however, there was no difference between these in the elderly group (P = 0.863). Instead, recurrent ACS was less frequent in patients with LDL-C ranging from 70 mg/dL to < 100 mg/dL than in those with LDL-C ≥ 100 mg/dL in the elderly group (P = 0.033). Statin use was associated with decreased recurrent ACS (P = 0.005); moreover, only using statins was an independent predictor in the elderly group (HR: 0.375; P = 0.007). CONCLUSIONS: Strict control of LDL-C to < 70 mg/dL was effective for reducing the incidence of recurrent ACS in younger patients. However, LDL-C < 100 mg/dL might be sufficient as the target value of LDL-C-lowering therapy for secondary prevention of ischemic events in Japanese elderly patients.