Stroke in a Young Age COVID-19 Patient: Vasculitis Feature and Changes in Cerebral Vessel Stenosis

Recent studies have shown that coronavirus disease-2019 (COVID-19) infection increased risk of stroke. Significant differences have been identified between the general population and COVID-19 stroke patients. There are unusual patterns of stroke occurred in COVID-19 patient are reported. Pathophysiologic theories about the relationship of COVID-19 infection and stroke are being published. Herein we report a rare case of stroke in a young COVID-19 patient, considered to be the result of vasculitis, and vessel changes that might have been caused by vasospasm based on serial brain imaging follow-up data. And we interpret this case based on pathophysiological characteristics of the severe acute respiratory syndrome coronavirus 2.

High-on-Aspirin Platelet Reactivity Differs Between Recurrent Ischemic Stroke Associated With Extracranial and Intracranial Atherosclerosis

Background@#and Purpose Ischemic stroke recurs despite the use of antiplatelet agents. Various mechanisms are involved in recurrence due to intracranial atherosclerosis (ICAS) and extracranial atherosclerosis (ECAS). High-on-aspirin platelet reactivity (HAPR) may differ between recurrent stroke due to ICAS and ECAS. @*Methods@#Patients with recurrent ischemic stroke as a result of large-artery atherosclerosis despite taking aspirin were enrolled consecutively. Ischemic stroke was classified as stroke due to ICAS or ECAS according to the location of the culprit stenosis. An aspirin reaction units (ARU) value of >550 IU was defined as HAPR. HAPR and its associated factors were compared between the two groups and also considering the mechanism of stroke. @*Results@#Among the 190 patients with recurrent stroke (111 with ICAS and 79 with ECAS), 36 (18.3%) showed HAPR. The ARU value was higher in the ECAS than the ICAS group (492± 83 vs. 465±78, mean±standard deviation; p=0.028), as was the proportion of patients with HAPR (27.8% vs. 12.6%, p=0.008). Being male and having stroke due to ECAS (reference = stroke due to ICAS: odds ratio=5.760; 95% confidence interval=2.154–15.403; p<0.001) was independently associated with HAPR. The ARU value differed according to the stroke mechanism, and was highest in those with artery-to-artery embolism. Artery-to-artery embolism was independently associated with HAPR in both the ICAS and ECAS groups. @*Conclusions@#Recurrent stroke due to ECAS was more strongly associated with HAPR and insufficient antiplatelet inhibition than was that due to ICAS. Artery-to-artery embolism was associated with HAPR in recurrent ischemic stroke as a result of ICAS or ECAS.

Effect of Transverse Sinus Stenting on Diffuse Leukoencephalopathy with Idiopathic Intracranial Hypertension

A diagnosis of idiopathic intracranial hypertension (IIH) can be made after excluding secondary causes. As stenosis of transverse sinuses is often revealed with IIH patients, transverse sinus stenting is used to release intracranial hypertension. It is rare to find a case of leukoencephalopathy secondary to IIH. Herein, we describe a case of diffuse leukoencephalopathy with IIH, which improved after stent insertion in the transverse sinus.

Cerebral Infarction Caused by Direct Cardiac Tumor Emboli Mixed with Thrombus

Cerebral infarction in cancer patients is often caused by thrombosis due to hypercoagulability, and in some cases, caused by direct tumor embolism. We report the case of cerebral infarction due to direct tumor embolism mixed with thrombus. Biopsy of blood clots obtained during thrombectomy is important for diagnosis. If there is a high risk of thrombosis among cancer patients with cerebral infarction, the use of appropriate antithrombotic agents along with maintaining a certain level of platelets should be considered.

Cyclophosphamide-Associated Reversible Cerebral Vasoconstriction Syndrome Presenting as Concurrent Cerebral Infarction and Subarachnoid Hemorrhage

Reversible cerebral vasoconstriction syndrome (RCVS) has several trigger factors, including physical exertion, pregnancy, and the intake of vasoconstrictive agents. These triggers activate the sympathetic nervous system and induce vasoconstriction, thereby leading to an ischemic or hemorrhagic stroke. In this study, we describe case of RCVS in a 73-year-old woman who complained of sudden bilateral leg weakness after taking cyclophosphamide for anti-neutrophil cytoplasmic antibody associated vasculitis. She was diagnosed with concurrent cerebral hemorrhage and cerebral infarction with multiple intracranial vasoconstrictions on imaging analyses.

Cyclophosphamide-Associated Reversible Cerebral Vasoconstriction Syndrome Presenting as Concurrent Cerebral Infarction and Subarachnoid Hemorrhage

Reversible cerebral vasoconstriction syndrome (RCVS) has several trigger factors, including physical exertion, pregnancy, and the intake of vasoconstrictive agents. These triggers activate the sympathetic nervous system and induce vasoconstriction, thereby leading to an ischemic or hemorrhagic stroke. In this study, we describe case of RCVS in a 73-year-old woman who complained of sudden bilateral leg weakness after taking cyclophosphamide for anti-neutrophil cytoplasmic antibody associated vasculitis. She was diagnosed with concurrent cerebral hemorrhage and cerebral infarction with multiple intracranial vasoconstrictions on imaging analyses.

Hemorrhagic Brain Metastasis in Angiosarcoma

Angiosarcomas are rare, but aggressive malignancies. Reports of brain metastasis are uncommon. In this report, we describe the clinical features of a 62 year-old man who presented with hemoptysis and right-sided weakness. Chest computed tomography showed multiple ill-defined part solid nodules in both lungs and brain magnetic resonance imaging showed multiple hemorrhagic bran masses. The patient underwent whole body proton emission tomography to identify biopsy site and showed multiple bone lesions. A right acetabulum biopsy in confirmed the diagnosis of angiosarcoma.

Anaphylaxis after Idarucizumab Infusion

No abstract available.

Near-Road Exposure and Impact of Air Pollution on Allergic Diseases in Elementary School Children: A Cross-Sectional Study

PURPOSE: The study aims to classify schools based on traffic pollutants and their complex sources, to assess the environment, to determine the state of allergic diseases among students using the International Study of Asthma and Allergies in children (ISAAC) questionnaire, and to assess their connection to air pollutants. MATERIALS AND METHODS: A total of seven schools were divided into three categories according to the characteristics of their surrounding environments: three schools in traffic-related zones, two schools in complex source zones I (urban), and two schools in complex source zones II (industrial complex). ISAAC questionnaires were administered and the 4404 completed questionnaires were analyzed. RESULTS: The frequency of asthma treatment during the past 12 months showed a significant increase (p<0.05) with exposure to NO2 [1.67, 95% confidence intervals (CIs) 1.03-2.71] in the complex source zones. The frequency of allergic rhinitis treatment during the past 12 months increased significantly with exposure to Black Carbon (1.60, 95% CIs 1.36-1.90) (p<0.001), SO2 (1.09, 95% CIs 1.01-1.17) (p<0.05), NO2 (1.18, 95% CIs 1.07-1.30) (p<0.01) for all subjects. CONCLUSION: In terms of supporting children's health, care, and prevention related to major spaces for children, such as school zones, spaces used in coming to and leaving school, playgrounds, and classrooms are essential to ensuring not only the safety of children from traffic accidents but also their protection from local traffic pollutants and various hazardous environmental factors.

Extended Use of Hypothermia in Elderly Patients with Malignant Cerebral Edema as an Alternative to Hemicraniectomy / 대한뇌졸중학회지

BACKGROUND AND PURPOSE: The use of decompressive hemicraniectomy (DHC) for the treatment of malignant cerebral edema can decrease mortality rates. However, this benefit is not sufficient to justify its use in elderly patients. We investigated the effects of therapeutic hypothermia (TH) on safety, feasibility, and functional outcomes in elderly patients with malignant middle cerebral artery (MCA) infarcts. METHODS: Elderly patients 60 years of age and older with infarcts affecting more than two-thirds of the MCA territory were included. Patients who could not receive DHC were treated with TH. Hypothermia was started within 72 hours of symptom onset and was maintained for a minimum of 72 hours with a target temperature of 33°C. Modified Rankin Scale (mRS) scores at 3 months following treatment and complications of TH were used as functional outcomes. RESULTS: Eleven patients with a median age of 76 years and a median National Institutes of Health Stroke Scale score of 18 were treated with TH. The median time from symptom onset to initiation of TH was 30.3±23.0 hours and TH was maintained for a median of 76.7±57.1 hours. Shivering (100%) and electrolyte imbalance (82%) were frequent complications. Two patients died (18%). The mean mRS score 3 months following treatment was 4.9±0.8. CONCLUSIONS: Our results suggest that extended use of hypothermia is safe and feasible for elderly patients with large hemispheric infarctions. Hypothermia may be considered as a therapeutic alternative to DHC in elderly individuals. Further studies are required to validate our findings.

A Comparison between Mechanical Thrombectomy and Intra-arterial Fibrinolysis in Acute Basilar Artery Occlusion: Single Center Experiences / 대한뇌졸중학회지

BACKGROUND AND PURPOSE: Recent advances in intra-arterial techniques and thrombectomy devices lead to high rate of recanalization. However, little is known regarding the effect of the evolvement of endovascular revascularization therapy (ERT) in acute basilar artery occlusion (BAO). We compared the outcome of endovascular mechanical thrombectomy (EMT) versus intra-arterial fibrinolysis (IAF)-based ERT in patients with acute BAO. METHODS: After retrospectively reviewed a registry of consecutive patients with acute ischemic stroke who underwent ERT from September 2003 to February 2015, 57 patients with acute BAO within 12 hours from stroke onset were enrolled. They were categorized as an IAF group (n=24) and EMT group (n=33) according to the primary technical option. We compared the procedural and clinical outcomes between the groups. RESULTS: The time from groin puncture to recanalization was significantly shorter in the EMT group than in the IAF group (48.5 [25.3 to 87.8] vs. 92 [44 to 179] minutes; P=0.02) The rate of complete recanalization was significantly higher in the EMT group than in the IAF group (87.9% vs 41.7%; P<0.01). The good outcome of the modified Rankin Scale score≤2 at 3 months was more frequent in the EMT group than in the IAF group, but it was not statistically significant (39.4% vs 16.7%; P=0.06). CONCLUSIONS: EMT-based ERT in patients with acute BAO is superior to IAF-based ERT in terms of the reduction of time from groin puncture to recanalization and the improvement of the rate of complete recanalization.

Dysphagia May Be an Independent Marker of Poor Outcome in Acute Lateral Medullary Infarction

BACKGROUND AND PURPOSE: The functional recovery after the lateral medullary infarction (LMI) is usually good. Little is known about the prognostic factors associated with poor outcome following acute LMI. The aim of this study was to identify the factors associated with poor long-term outcome after acute LMI, based on experiences at a single center over 11 years. METHODS: A consecutive series of 157 patients with acute LMI who were admitted within 7 days after symptom onset was evaluated retrospectively. Clinical symptoms were assessed within 1 day after admission, and outcomes were evaluated over a 1-year period after the initial event. The lesions were classified into three vertical types (rostral, middle, and caudal), and the patients were divided into two groups according to the outcome at 1 year: favorable [modified Rankin Scale (mRS) score or =2). RESULTS: Of the 157 patients, 93 (59.2%) had a favorable outcome. Older age, hypertension, dysphagia, requirement for intensive care, and pneumonia were significantly more prevalent in the unfavorable outcome group. The frequencies of intensive care (13%) and mortality (16.7%) were significantly higher in the rostral lesion (p=0.002 and p=0.002). Conditional logistic regression analysis revealed that older age and initial dysphagia were independently related to an unfavorable outcome at 1 year [odds ratio (OR)=1.04, 95% confidence interval (95% CI)=1.001-1.087, p=0.049; OR=2.46, 95% CI=1.04-5.84, p=0.041]. CONCLUSIONS: These results suggest that older age and initial dysphagia in the acute phase are independent risk factors for poor long-term prognosis after acute LMI.

Therapeutic Hypothermia after Decompressive Craniectomy in Malignant Cerebral Infarction / 대한구급학회지

Decompressive hemicraniectomy followed by subsequent therapeutic hypothermia can reduce mortality in patients with malignant cerebral infarction without significantly increasing risk. We report three cases of malignant cerebral infarction treated with hemicraniectomy followed by hypothermia. Case 1 received elective decompressive surgery and hypothermia. Case 2 developed subsequent cerebral infarction with uncal herniation. Therefore, emergent decompressive surgery and hypothermia was performed in this case. Despite surgery and hyperosmolar therapy, case 3 received hypothermia treatment for refractory increased intracranial pressure. All patients survived with a score of 4 or 5 on the modified Rankin scale. Therefore, we suggest that application of hypothermia after hemicraniectomy is safe and feasible. Several possible modifications can be made to improve the management strategy in order to increase the benefits of hypothermia treatment.

Repeated Hypothermia for Rebound Cerebral Edema after Therapeutic Hypothermia in Malignant Cerebral Infarction / 대한구급학회지

Malignant cerebral infarction has a high risk of fatal brain edema and increased intracranial pressure with cerebral herniation causing death. One of the major causes of death is a rebound cerebral edema during rewarming phase. A 66-year-old male patient presented with the right hemiplegia and global aphasia due to malignant cerebral infarction in the whole territory of middle cerebral artery with the occlusion of the proximal internal carotid artery. Being refused decompressive hemicraniectomy, he received the therapeutic hypothermia for 6 days. After rewarming for 6 hours, mentality was suddenly decreased and dilated left pupil. Follow-up CT revealed that midline shifting was more aggravated. We decided on repeated hypothermia for rebound cerebral edema and successfully controlled. We report our experience with repeated hypothermia for rebound cerebral edema following therapeutic hypothermia in malignant cerebral infarction.

Spontaneous Carotid Cavernous Fistula in a Case with Protein S Deficiency that Newly Developed Ophthalmoplegia after Embolization

BACKGROUND: Carotid cavernous fistula (CCF) is an abnormal communication between the carotid artery and the cavernous sinus. The pathogenesis of spontaneous CCF remains unclear, although sinus thrombosis is known to be a predisposing factor for dural arteriovenous fistula. Because spontaneous CCFs are mainly of the dural type, we considered that thrombogenic conditions, such as, protein S deficiency might be associated with CCF. CASE REPORT: A 42-year-old woman complained of conjunctival injection and retro-orbital pain that first appeared 1-month before visiting our hospital. She had no history of head trauma or intracranial surgery. Exophthalmos and chemosis were observed in her left eye, which also had lower visual acuity and higher intraocular pressure than the right eye. Magnetic resonance images and cerebral angiography revealed a left dural CCF. Her protein S was low, at 41% (normal range: 70-140%), but other hematologic values related to coagulation were normal. Her symptoms were relieved after initial transvenous coil embolization. However, a newly developed sixth-nerve palsy was detected 4 days after initial embolization. Follow-up angiography revealed a minimal shunt, and thus transvenous coil embolization was repeated. Two days later, the ophthalmoplegia started reducing, and 1-month later it had almost disappeared. CONCLUSIONS: To the best of our knowledge, this is the first report of spontaneous dural CCF in a Korean patient with concurrent protein S deficiency. Interestingly, transient sixth-nerve palsy developed after transvenous coil embolization in this patient. This additional symptom caused by the residual fistula was relieved after additional transarterial embolization.

Streptococcus viridans Meningitis After Epidural Nerve Block

We report herein a case of meningitis due to Streptococcus viridans that occurred after epidural nerve block. The low virulence of S. viridans resulted in milder clinical symptoms and signs than are usually observed for bacterial meningitis, thus mimicking viral meningitis. The infection may have originated from the oral cavity of the medical personnel, and so S. viridans infection should be included in the differential diagnosis of meningitis subsequent to spinal manipulation.

Thrombolytic Therapy of Pulmonary Thromboembolism in Probable Sporadic Creutzfeldt-Jakob Disease

The effect of intravenous recombinant tissue plasminogen activator for patients with Creutzfeldt-Jakob disease (CJD) has yet to be determined. A woman with rapidly progressive cognitive decline, cerebellar dysfunction, and extrapyramidal symptoms, diagnosed as probable sporadic CJD, was complicated with pulmonary thromboembolism and systemic hypotension. Her vital signs were restored without brain parenchymal hemorrhage after intravenous thrombolysis. The presence of diffuse brain lesions in CJD did not increase the hemorrhagic complications associated with intravenous thrombolysis, which differs from an ischemic vascular event.

Steroid Unresponsive Neuromyelitis Optica Improved With Plasmapheresis

Plasmapheresis is an emerging treatment for intravenous steroid-resistant neuromyelitis optica (NMO). We present the case of a 16-year-old girl who suffered from intravenous steroid-resistant NMO and whose neurological status improved markedly after treatment with plasmapheresis. This is the first report on the effectiveness of plasmapheresis in NMO in Korea. kwoo@plaza.snu.ac.kr