Ability of NT-pro-BNP to Diagnose Cardioembolic Etiology in Patients with Acute Ischemic Stroke.

Background Cardioembolic stroke (CE) is usually associated with a larger ischemic area leading to higher morbidity and mortality rates. No biomarkers for CE are available, which causes difficulty in differential diagnosis of CE from other subtypes of acute ischemic stroke. Methods: We prospectively evaluated consecutive patients with acute ischemic stroke to identify biomarkers that could distinguish between CE and other subtypes of acute ischemic stroke. Etiological diagnoses were identified according to the National Institute of Neurological Disorders and Stroke (NINDS) 111 classification using clinical examinations, computed tomography (CT), magnetic resonance imaging (MRI), cardiac evaluations, and other tests. The biomarkers N-terminal pro-brain natriuretic peptide (NT-pro-BNP), Thrombin-Antithrombin III Complex (TAT), and D-dimer were determined in blood samples collected within 48 hours of onset and compared between groups with and without CE. Non- CE consisted of atherothrombotic brain infarction (ATBI), lacunar infarction (LI), and other stroke subtypes of unknown cause (other). Results: This study included 279 patients diagnosed with acute ischemic stroke. Serum levels of NT-pro- BNP were significantly higher in those with than in those without CE stroke (p<0.0001). Analysis of receiver operating characteristics (ROC) curves indicated that an NT-pro-BNP cutoff of 332 pg/mL provided optimal sensitivity (98.3%) and specificity (75.8%) for distinguishing CE from non-CE. Conclusions: Serum levels of NT-pro-BNP may help in diagnosis of CE during the acute phase and thus allow appropriate therapy t6 prevent subsequent cardiogenic stroke.

[A case of trigeminocardiac reflex in the pterional approach].

Trigeminocardiac reflex (TCR) is a type of vasovagal reflex which happens in stimulation of the trigeminal nerve. We present a case of TCR in the pterional approach for clipping of an unruptured anterior communicating artery (Acom) aneurysm. A 69-year-old female was evaluated because of syncope. MRI showed incidentally Acom aneurysm. During the operation for clipping this aneurysm, only when we manipulated the dura attached to the sphenoid ridge, a total of three times, asystole appeared temporarily. In this case, a branch of the trigeminal nerve accompanying the middle meningeal artery was stimulated, then TCR may have been induced, leading to asystole. Furthermore, it seems that remifentanil used for anesthesia is related to TCR.

Extracranial internal carotid artery dissection caused by compression from a giant osteophyte due to atlantoaxial osteoarthritis: case report.

Deformed osseous structures have been reported as rare causes of extracranial internal carotid artery (ICA) dissection, including the styloid process and the hyoid bone. Here, the authors describe the first known case of symptomatic ICA dissection caused by a giant osteophyte due to atlantoaxial osteoarthritis. The left ICA was fixed at the skull base and at the ICA portion compressed by the osteophyte, and it was highly stretched and injured between the two portions during neck rotation. The patient was successfully treated with ligation of the affected ICA following balloon test occlusion. Atlantoaxial osteoarthritis should be considered in the differential diagnosis of ICA dissection in patients with a severely deformed cervical spine.

Intraoperative Transcranial Motor-Evoked Potentials Predict Motor Function Outcome in Intracerebral Hemorrhage Surgery.

OBJECTIVE: Prediction of motor function after intracerebral hemorrhage (ICH) often poses a diagnostic challenge. This study was performed to investigate whether intraoperative monitoring of motor-evoked potentials (MEPs) could predict postoperative motor function recovery. METHODS: We reviewed 16 consecutive patients undergoing evacuation of supratentorial ICH with hemiplegia between June 2011 and October 2014. Patients were categorized according to the results of MEPs before and after evacuation of hematoma. The correlation between detection of MEPs and prognosis of motor function was analyzed. RESULTS: In 10 of 16 cases (62%), stable MEPs were detected before and after evacuation of hematoma, and postoperative motor function was improved in all cases, including 3 cases with severe preoperative motor impairment on manual muscle test (1-2). In 3 cases (19%) in which MEPs were not detected throughout the procedure, motor function was not improved. In the other 3 cases (19%), MEPs were not measured before evacuation of ICH but were detected after evacuation despite poor prognosis of motor function. The results of postevacuation MEPs were considered false-negative results. Predictions using pre-evacuation MEP results were completely consistent with prognosis for recovery, whereas MEPs obtained during and after evaluation were useful for monitoring. CONCLUSIONS: Intraoperative MEPs may indicate preservation of pyramidal tracts, and pre-evacuation MEPs can predict motor function outcome after ICH surgery.

[Japanese CADASIL case with limited dementia who had the Notch 3 R141C mutation].

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is a rare hereditary disease characterized by recurrent transient ischemic attacks (TIA) and strokes, and vascular dementia caused by point mutations of the Notch 3 gene. Here, we report a Japanese CADASIL case who displayed limited dementia and had the Notch 3 R141C mutation. The relationship between pathogenesis and the mutation site in Notch 3 is discussed based on the case presented here.

Dural arteriovenous fistula involving the superior sagittal sinus following sinus thrombosis--case report.

A 57-year-old woman presented with a dural arteriovenous fistula (AVF) involving the superior sagittal sinus (SSS) based upon serial radiological examinations. Her chief complaints were headache and vomiting. Cerebral angiography and magnetic resonance (MR) venography revealed the sinus thrombosis involving the SSS, the bilateral transverse sinuses (TSs), and the right sigmoid sinus. Her symptoms disappeared after anticoagulant therapy. Follow-up MR venography revealed almost complete recanalization of the occluded sinuses, followed by restenosis of the SSS and the left TS and occlusion of the right TS without symptoms. She developed transient right hemiparesis 13 months after the initial onset. Cerebral angiography revealed a dural AVF involving the SSS with cortical reflux into the left frontoparietal region. The dural AVF was occluded by transarterial and transvenous embolization. Her symptom disappeared during the follow-up period.

Activation of the serotonergic system by pedaling exercise changes anterior cingulate cortex activity and improves negative emotion.

Pedaling exercise (PE) of moderate intensity has been shown to ease anxiety and discomfort; however, little is known of the changes that occur in brain activities and in the serotonergic (5-HT) system after PE. Therefore, this study was conducted for the following reasons: (1) to localize the changes in the brain activities induced by PE using a distributed source localization algorithm, (2) to examine the changes in frontal asymmetry, as used in the Davidson model, with electroencephalography (EEG) activity, and (3) to examine the effect of PE on the 5-HT system. A 32-channel EEG was used to record before and after PE. Profile of Mood States tests indicated that there was a significant decrease in tension-anxiety and a significant increase in vigor after PE. A standardized low-resolution brain electromagnetic tomography analysis showed a significant decrease in brain activities after PE in the alpha-2 band (10-12.5 Hz) in the anterior cingulate cortex (ACC). Moreover, a significant increase in frontal EEG asymmetry was observed after PE in the alpha-1 band (7.5-10 Hz). Urine 5-HT levels significantly increased after PE. Urine 5-HT levels positively correlated with the degree of frontal EEG asymmetry in the alpha-1 band and negatively correlated with brain activity in ACC. Our results suggested that PE activates the 5-HT system and consequently induces increases in frontal EEG asymmetry in the alpha-1 band and reductions of brain activity in the alpha-2 band in the ACC region.

Ruptured internal carotid artery bifurcation aneurysm presenting with only intracerebral hemorrhage without subarachnoid hemorrhage--case report.

A 55-year-old man presented with intracerebral hemorrhage (ICH) without subarachnoid hemorrhage (SAH) manifesting as acute onset of consciousness disturbance and right hemiparesis. Computed tomography showed ICH mainly localized in the left putamen, but no evidence of SAH. Magnetic resonance angiography demonstrated a cerebral aneurysm originating from the bifurcation of the left internal carotid artery, which was considered to be responsible for the ICH. The patient underwent emergent intravascular surgery for coil embolization of the aneurysm, and his neurological symptoms gradually recovered with rehabilitation after surgery. Although ICH without SAH is a rare presentation of cerebral aneurysm, ruptured cerebral aneurysm should be considered as a potential cause of ICH. The localization and extent of ICH may be suggestive of latent cerebral aneurysm in such cases.

Mechanical clot disruption following intravenous recombinant tissue plasminogen activator administration in non-responders.

The efficacy of selecting non-responders to intravenous recombinant tissue plasminogen activator (rt-PA) for mechanical clot disruption (MCD) was investigated based on cerebral angiography in the acute stage following rt-PA therapy. rt-PA therapy using 0.6 mg/kg was performed in eligible patients within 3 hours of onset. Patients who did not show recanalization on cerebral angiography 1 hour after rt-PA initiation immediately underwent MCD. Clinical outcome was evaluated by National Institutes of Health Stroke Scale (NIHSS) score at baseline, 24 hours, and 1 month, and by modified Rankin scale (mRS) score at 3 months. Eighteen patients were initially treated with intravenous rt-PA, with mean time from stroke onset to rt-PA therapy of 120 +/- 27 minutes. Eight of these patients underwent MCD. Seven of these eight patients had complete recanalization. Time to recanalization by percutaneous transluminal angioplasty from stroke onset was 258 +/- 59 minutes. Final recanalization was achieved in 16 of the 18 patients. Baseline NIHSS score improved significantly at 1 month (median from 22.5 to 4). Twelve of the 18 patients treated according to our protocol were classified as independent (mRS scores 0-2). No patients had symptomatic hemorrhage. MCD for non-responders determined by cerebral angiography at the end of intravenous rt-PA infusion can decrease the time to recanalization and improve recanalization rates, leading to good clinical outcome after acute stroke.

Central neurocytoma presenting with massive hemorrhage leading to coma--case report.

A 21-year-old man presented with a hemorrhagic central neurocytoma manifesting as acute onset of disturbance of consciousness and right hemiparesis. Computed tomography (CT) demonstrated a tumor in the left lateral ventricle during the course of evaluation for mental alteration 12 days before onset, but the tumor was left untreated because the patient refused to visit a neurosurgical institution. CT on admission revealed a large mass lesion located in the body of the lateral ventricle associated with massive intratumoral and intraventricular hemorrhage. He underwent emergent surgery for evacuation of the tumor with hematoma, and his neurological symptoms gradually recovered after surgery. The present case highlights the possibility of rapid deterioration of symptoms by massive hemorrhage from central neurocytoma. Surgical intervention should thoroughly be considered, if intratumoral hemorrhage is present, as hemorrhage from the central neurocytoma may lead to serious neurological complications.

Small artery dementia in Japan: radiological differences between CADASIL, leukoaraiosis and Binswanger's disease.

CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy) is a hereditary small artery disease which is phenotypically similar to Binswanger's disease (BD), a nonhereditary form of small artery disease. Recent studies have indicated that lesions in the temporopolar, medial frontopolar areas and external capsule are frequently seen in Caucasian patients with CADASIL. However, it remains unclear whether magnetic resonance (MR) imaging findings are helpful in diagnosing small artery disease outside countries with Caucasian populations, since CADASIL is rare despite the high prevalence of small artery disease in Japan. We examined 58 patients with small artery disease, all of whom were devoid of major vessel occlusion or severe stenosis. These patients included 7 patients from 3 families with CADASIL, 27 nondemented patients with extensive leukoaraiosis (LA) and 24 patients with BD. On T(2)-weighted MR images, hyperintensities in the temporopolar areas were observed in all 7 patients with CADASIL, whereas these lesions were observed in only 1 subject from each of the nondemented LA and BD groups. Hyperintensities in the medial frontopolar areas were seen in 4 of the 7 patients with CADASIL (57%) and in 14 of the 24 patients with BD (58%), and were more frequent than in the nondemented LA group (4 of the 27 patients; 15%). In contrast, hyperintensities in the external capsule were frequently observed in all groups. Therefore, temporopolar lesions can also serve as diagnostic markers for CADASIL in non-Caucasian patients.