Clinical features and efficacy of reperfusion therapy in minor ischemic stroke patients with atrial fibrillation.

The efficacy of reperfusion therapy (RT) using intravenous infusion of recombinant tissue plasminogen activator and/or endovascular therapy for minor ischemic stroke (MIS) has not yet been established. The present study aimed to elucidate the clinical features of MIS patients with atrial fibrillation (AF) and examine whether they could be potential candidates for RT. Data of MIS patients, defined as those with a score ≤ 5 on the National Institute of Health Stroke Scale, were extracted from patients admitted to our hospital between 2006 and 2018, and clinical characteristics were compared between the AF and non-AF groups. Thereafter, the impact of RT on outcomes in the AF- group was evaluated using the modified Rankin scale (mRS) score 3 months after onset and compared to that of standard medical therapy (SMT) using propensity score matching (PSM). Of 10,483 stroke patients, 3003 were shortlisted, and 457 AF patients and 2546 non-AF patients were finally selected. Patients in the AF group had more RT (13.3% vs. 5.7%, p < 0.001) than those in the non-AF group. Using PSM, 53 patients each were extracted from the AF-RT and AF-SMT groups. The frequencies of mRS = 0 or 1 for the AF-RT and AF-SMT groups were 69.8% and 64.2% (p = 0.536), respectively, with a significant difference in mRS = 0 (56.5% vs. 34.0%, p = 0.019). The present study found that MIS patients with AF underwent more RT than those without AF and that RT compared favorably with SMT for them; further study is warranted to examine whether these patients could be good candidates for RT.

[Clinical, epidemiological, and etiological studies of adult aseptic meningitis: a report of 12 cases of herpes simplex meningitis, and a comparison with cases of herpes simplex encephalitis].

We treated 437 cases of adult aseptic meningitis and 12 cases (including 2 recurrent patients; age, 31.8 ± 8.9 years; 7 females) of herpes simplex meningitis from 2004 to 2016. The incidence rate of adult herpes simplex meningitis in the cases with aseptic meningitis was 2.7%. One patient was admitted during treatment of genital herpes, but no association was observed between genital herpes and herpes simplex meningitis in the other cases. The diagnoses were confirmed in all cases as the cerebrospinal fluid (CSF) was positive for herpes simplex virus (HSV)-DNA. For diagnosis confirmation, the DNA test was useful after 2-7 days following initial disease onset. Among other types of aseptic meningitis, the patients with herpes simplex meningitis showed relatively high white blood cell counts and relatively high CSF protein and high CSF cell counts. CSF cells showed mononuclear cell dominance from the initial stage of the disease. During same period, we also experienced 12 cases of herpes simplex encephalitis and 21 cases of non-hepatic acute limbic encephalitis. Notably, the patients with herpes simplex meningitis were younger and their CSF protein and cells counts were higher than those of the patients with herpes simplex encephalitis.

Clinical, epidemiological and etiological studies of adult aseptic meningitis: Report of 11 cases with varicella zoster virus meningitis.

We treated 11 cases (52.7 ± 14.9 years, all male) with varicella zoster virus (VZV) meningitis and 437 cases with adult aseptic meningitis from 2004 to 2016. The incidence rate of adult VZV meningitis in the cases with aseptic meningitis was 2.5%. Herpes zoster infections are reported to have occurred frequently in summer and autumn. VZV meningitis also occurred frequently in the similar seasons, in our patients. The diagnoses were confirmed in 9 cases with positive VZV-DNA in the cerebrospinal fluid and in 2 cases with high VZV-IgG indexes (> 2.0). For diagnosis confirmation, the former test was useful for cases within a week of disease onset, and the latter index was useful for cases after a week of disease onset. Zoster preceded the meningitis in 8 cases, while the meningitis preceded zoster in 1 case, and 2 cases did not have zoster (zoster sine herpete). Two patients were carriers of the hepatitis B virus, 1 patient was administered an influenza vaccine 4 days before the onset of meningitis, and 1 patient was orally administered prednisolone for 2 years, for treatment. Their immunological activities might have been suppressed. The neurological complications included trigeminal neuralgia, facial palsy (Ramsay Hunt syndrome), glossopharyngeal neuralgia, and Elsberg syndrome. Because the diseases in some patients can become severe, they require careful treatment.

Ability of the Ankle Brachial Index and Brachial-Ankle Pulse Wave Velocity to Predict the 3-Month Outcome in Patients with Non-Cardioembolic Stroke.

AIM: Both the ankle brachial index (ABI) and brachial-ankle pulse wave velocity (baPWV) are surrogates for atherosclerosis. In this study, we aimed to evaluate the ability of ABI and baPWV to predict stroke outcome in patients with first-ever non-cardioembolic stroke. METHODS: This study included consecutive patients with first-ever non-cardioembolic stroke admitted within 1 week after onset to Ota Memorial Hospital between January 2011 and December 2013. Baseline characteristics and National Institutes of Health stroke scale scores at admission were noted. ABI and baPWV were evaluated within 5 days of admission. The patients were categorized according to ABI (cut-off 0.9) and baPWV (cut-off 1870 cm/s) determined using the receiver operation curve for poor outcome. Clinical outcomes were defined based on the modified Rankin scale (mRS) scores 3 months after stroke onset as good (0 and 1) or poor (2-6). RESULTS: A total of 861 patients were available for evaluation. ABI ＜0.9 and baPWV ＞1870 cm/s were associated with poor outcome in the univariate analysis (p＜0.001 and p＜0.001, respectively). After adjusting for factors that showed differences between groups, ABI ＜0.9 was associated with poor outcome. Among patients with ABI ≥ 0.9, higher baPWV showed a slight association with poor outcome after adjustment [odds ratio 1.46 (95% CI 0.95-2.27)]. CONCLUSION: Our study suggests that the stroke outcome can be predicted using ABI and to an extent using baPWV when ABI ≥ 0.9 in patients with non-cardioembolic stroke.

Dementia with Lewy bodies presenting marked tongue protrusion and bite due to lingual dystonia: A case report.

We report the patient of a 53-year-old woman who developed subacute-onset marked tonge protrusion and bite. She was diagnosed as dementia with Lewy bodies (DLB) from the clinical features including progressive cognitive decline, visual hallucinations, parkinsonism, and severe insomnia and depression, and the radiological finding of low dopamine transported uptake in basal ganglia by Dat SCAN and low blood circulation in occipital lobe of cerebrum. The patient received 600 mg doses of levodopa for over a year, followed by rotigotine and ropinirole with a rapid increase of dosage. It is believed that these treatments stimulated and sensitized dopamine D1 receptors, thereby inducing lingual dystonia. Furthermore, the patient demonstrated dyspnea and attacks of apnea caused by the closure of bilateral vocal cords due to laryngeal dyskinesia. After initiation of the neuroleptic, olanzapine, for a short duration, the high dose of levodopa overlapped with neuroleptic sensitivity, suggesting DOPA-induced dystonia and dyskinesia. This interaction can sometimes lead to lethal adverse events, and must be considered very important when treating patients with DLB.

Brain Natriuretic Peptide and Particular Left Ventricle Segment Asynergy Associated with Cardioembolic Stroke from Old Myocardial Infarction.

BACKGROUND: It is important to determine the usage of anticoagulants by defining the actual risk of cardioembolic stroke in patients with old myocardial infarction. In the present study, we aimed to more precisely evaluate the risks of each segment associated with cardioembolic stroke using a 16-segment model. The usage of the plasma brain natriuretic peptide (BNP) associated with cardioembolic stroke was also evaluated in comparison with a left ventricle ejection fraction less than 40%. METHODS: There were a total of 190 ischemic stroke patients who had premorbid myocardial infarction. The study included a total of 143 ischemic stroke patients with old myocardial infarction who were available for evaluation and excluded patients with atrial fibrillation or acute myocardial infarction. Their left ventricle wall motion abnormality and the level of plasma BNP at their admission were analyzed. RESULTS: Hypertension and a plasma BNP level of 206.9 pg/mL or higher, determined from the receiver operating characteristic curve, were independently associated with cardioembolic stroke (χ(2) = 35.6, R(2) = .30, P < .001). Adjusting for these factors, statistically independent high risk was observed at the basal-inferior, basal-inferolateral, mid-anterior, mid-anteroseptal, apical-anterior, and apical-septal left ventricles. CONCLUSION: High plasma BNP levels and left ventricular wall motion abnormalities in the segments perfused with left anterior descending coronary artery or right coronary artery show a high risk for cardioembolic stroke in patients with old myocardial infarction. Considering these factors, it could be possible to more precisely define the risk of cardioembolic stroke and to perform appropriate antithrombotic treatments in old myocardial infarction patients.

[Intracerebral hemorrhage associated with nephrotic syndrome-Prevalemce and clinical characteristics].

Of the 11,161 cases of stroke observed for over 9 years, 21 cases in which both levels of serum albumin and cholesterol were < 3 g/dl and > 250 mg/dl, respectively, were identified. Out of these 21 cases, cases of severe proteinuria, i.e., nephrotic syndrome were selected. These included 10 cases of arterial ischemic thrombosis, 2 cases of cerebral venous sinus thrombosis, and 4 cases of intracerebral hemorrhage. The incidence of intracerebral hemorrhage associated with nephrotic syndrome was 0.18% of total stroke or 0.036% intracerebral hemorrhage. Nephrotic syndrome essentially induced a hypercoagulable state. The 4 cases with intracerebral hemorrhage associated with nephrotic syndrome, however, had strong risk factors for intracerebral hemorrhage, suggesting that they overcame the risk for thrombophilia. The diseases associated with the nephrotic syndrome were diabetic nephropathy and amyloidosis in 3 cases and in 1 case, respectively. The nephrotic syndrome tends to be associated with a risk for venous or arterial thrombosis. In addition, we must pay attention to intracerebral hemorrhage associated with nephrotic syndrome in cases of stroke.

[Posterior reversible encephalopathy syndrome of the midbrain and hypothalamus - a case report of uremic encephalopathy presenting with hypersomnia].

We report the case of a 73-year-old woman presenting with hypersomnia and loss of appetite. She suffered from diabetic nephropathy without receiving dialysis, in addition to hypertension, which was well controlled without marked fluctuation. There were no objective neurological findings. Her laboratory findings showed renal failure with 3.7 mg/dl of serum creatinine and decreased serum sodium and potassium. Brain magnetic resonance imaging (MRI) showed posterior reversible encephalopathy syndrome (PRES) with vasogenic edema, which was distributed in the dorsal midbrain, medial thalamus, and hypothalamus. After we addressed the electrolyte imbalance and dehydration, her symptoms and MRI findings gradually improved, but faint high signals on MRI were still present 3 months later. Orexin in the cerebrospinal fluid was decreased on admission, but improved 6 months later. We diagnosed uremic encephalopathy with atypical form PRES showing functional disturbance of the hypothalamus.

[Clinical, epidemiological and etiological studies of adult aseptic meningitis: Report of 13 cases with mumps meningitis].

We experienced 13 cases (29.8 ± 7.0 years) of mumps meningitis and 365 cases of adult aseptic meningitis during 11 years from 2004 to 2014. A small epidemic of mumps occurred for 3-4 years, and the incidence rate of adult mumps meningitis coincided with the epidemic without seasonal fluctuation. Parotitis was observed in 8 of the 13 mumps meningitis patients (61.5%) and orchitis in 2 of 7 male patients (28.6%). There were no differences in clinical manifestations, laboratory findings, and outcome between patients with adult mumps meningitis and those with echovirus 9 meningitis (9 patients), except for the low frequency of nausea/vomiting and a high percentage of mononuclear cells of the cerebrospinal fluid in those with mumps. Eight patients had contact with persons with mumps before the symptomatic stage of meningitis. Only one patient had received mumps vaccination in childhood. On the basis of the values of the anti-mumps IgM and IgG antibodies, we speculated primary infection and the re-infection of mumps in 6 and 2 patients, respectively. Moreover, second vaccine failure was suggested in the vaccinated patient.

[Chronic intracerebral hemorrhage in the basal ganglia: Report of two cases and prevalence].

Two patients presented with chronic intracerebral hemorrhage (CIH) in the basal ganglia. A 48-year-old man (Case 1) was admitted to our hospital because of hypertensive right putaminal hemorrhage. On day 14, his hematoma surrounding the edema had grown without re-bleeding as seen on head CT, which was then removed endoscopically on day 28. Biopsied specimen of the hematoma capsule showed granulomatous tissue with vascularity. A 54-year-old man (Case 2) was admitted to our hospital because of bilateral intracerebral hemorrhage in the basal ganglia of the right putamen and left thalamus. On head CT, both hematomas were found to be enlarged without change in his symptoms on the 11th day after onset. His symptoms and signs subsided with medical treatment for 4 weeks. Cerebral angiography showed no abnormality of cerebral vessels. The patient had intracerebral hemorrhage in the basal ganglia or cerebral lobes 5 times in the past 10 years. Although no arterial or venous abnormality was detected by cerebral angiography and MRI/MRA, the abnormality of vessels including capillaries was strongly suggested. CIH should be considered a possibility when the symptom or hematoma does not improve even 2 weeks after the onset. The prevalence of CIH in our hospital was 0.08% of total intracerebral hemorrhages and 0.15% of hemorrhages in the basal ganglia.

[A child who developed internal carotid artery obstruction 2 weeks after incurring an intraoral blunt injury: A case report].

This report describes a 9-year-old boy with an internal carotid artery (ICA) injury caused by a fall with the blunt edge of a toothbrush held in the mouth. The initial injury appeared trivial, but 2 weeks later, generalized convulsion and left hemiparesis occurred. Magnetic resonance imaging and magnetic resonance angiography revealed an infarction of the right striatum, right ICA occlusion, and stenosis of the right middle cerebral artery, which were caused by the dissection or intimal damage of the ICA due to the blunt trauma. For children, intraoral blunt trauma sometimes causes ICA occlusion and consecutive strokes after the latent interval of days to weeks. Therefore, a careful clinical observation is essential to prevent overlooking strokes. This patient was an unique case with a long latent interval among the past literatures.