[A case of atezolizumab- and bevacizumab-induced myositis showing high intensity in the pterygoid muscles, soft palate, and tongue on STIR-MRI].

A 61-year-old woman was treated with atezolizumab plus bevacizumab for hepatocellular carcinoma with peritoneal dissemination. Blood tests revealed elevated creatine kinase (CK) that peaked at 2,657 U/l. After two cycles of atezolizumab plus bevacizumab combination therapy, she complained of progressive dysarthria and dysphagia. Needle electromyography showed myopathic changes. Initial MRI showed high signal intensity in the orbicularis oris muscle, soft palate, tongue, pterygoid muscles, and paravertebral muscles on STIR images. Myositis-specific autoantibodies were not detected. Based on these findings, the patient was diagnosed with immune checkpoint inhibitor-associated myositis. The clinical symptoms improved after administration of oral prednisone, and follow-up MRI showed reduced extent of areas of high signal intensity and almost complete resolution of signal abnormality in the paravertebral muscles. The CK level normalized after 1 months of oral steroid administration. MRI of the head and neck, including the tongue and soft palate, may be useful in diagnosis and for evaluating therapeutic efficiency in cases of bulbar symptoms that occur following the introduction of immune checkpoint inhibitors.

Quantitative and Morphological Assessment of Computed Tomography-depicted Gynecomastia in Spinal and Bulbar Muscular Atrophy.

RATIONALE AND OBJECTIVES: To evaluate the prevalence, size, and characteristics of gynecomastia on thoracic computed tomography (CT) in patients with spinal and bulbar muscular atrophy (SBMA) or amyotrophic lateral sclerosis (ALS), compared to those of patients with myasthenia gravis (as controls). MATERIALS AND METHODS: A total of 189 male patients (SBMA [n = 15]; ALS [n = 76]; control [n = 98]) who underwent thoracic computed tomography were included. The size of breast glandular tissue diameters, and characteristic of CT-depicted gynecomastia were compared. RESULTS: On multivariate logistic regression analysis, mean breast glandular tissue diameter (adjusted odds ratio [aOR] 1.13, 95% confidence interval [CI] 1.08-1.19), maximum breast glandular tissue diameter (aOR 1.14, 95% CI 1.08-1.20), prevalence of CT-depicted gynecomastia (aOR 21.71, 95% CI 5.39-87.38), dendritic or diffuse pattern of gynecomastia (aOR 35.30, 95% CI 8.02-155.40), and bilateral gynecomastia (aOR 41.96, 95% CI 10.20-172.69) were positively associated with SBMA, but not ALS. On receiver operating characteristic (ROC) analysis, the area under the curve of the mean breast tissue diameter for predicting SBMA was 0.92 with the optimal cutoff value of 16.5 mm. The ROC analysis showed that a maximum breast tissue diameter of 18.6 mm can also effectively distinguish SBMA from controls. CONCLUSION: These findings suggest that the evaluation of breast glandular tissue on thoracic CT could be a screening examination to distinguish SBMA patients and assist in its differential diagnosis.

Heterogeneity between proximal and distal aspects of occlusive thrombi on pretreatment imaging in acute ischemic stroke.

BACKGROUND: The potential heterogeneity in occlusive thrombi caused by in situ propagation by secondary thrombosis after embolic occlusion could obscure the characteristics of original thrombi, preventing the clarification of a specific thrombus signature for the etiology of ischemic stroke. We aimed to investigate the heterogeneity of occlusive thrombi by pretreatment imaging. METHODS: Among consecutive stroke patients with acute embolic anterior circulation large vessel occlusion treated with thrombectomy, we retrospectively reviewed 104 patients with visible occlusive thrombi on pretreatment non-contrast computed tomography admitted from January 2015 to December 2018. A region of interest was set on the whole thrombus on non-contrast computed tomography under the guidance of computed tomography angiography. The region of interest was divided equally into the proximal and distal segments and the difference in Hounsfield unit densities between the two segments was calculated. RESULTS: Hounsfield unit density in the proximal segment was higher than that in the distal segment (mean difference 4.45; p < 0.001), regardless of stroke subtypes. On multivariate analysis, thrombus length was positively correlated (ß = 0.25; p < 0.001) and time from last-known-well to imaging was inversely correlated (ß = -0.0041; p = 0.002) with the difference in Hounsfield unit densities between the proximal and distal segments. CONCLUSIONS: The difference in density between the proximal and distal segments increased as thrombi became longer and decreased as thrombi became older after embolic occlusion. This time/length-dependent thrombus heterogeneity between the two segments is suggestive of secondary thrombosis initially occurring on the proximal side of the occlusion.

[Cerebral amyloid angiopathy-related transient focal neurological episodes with diffusion-weighted imaging hyperintense lesions in subcortical white matter and cortical superficial siderosis].

A 72-year-old man presented with two episodes of migratory left-sided paresthesia lasting 10 min. At the first episode, diffusion-weighted imaging hyperintense lesions (DWIHLs) were seen in the right parietal lobe, suggesting an initial diagnosis of acute ischemic stroke, for which we administered antiplatelet therapy for secondary prevention. Four months later, he again developed transient migratory left-sided paresthesia. Gradient-echo T2*-weighted imaging at this time showed disseminated cortical superficial siderosis (cSS) and strictly cerebral microbleeds around the DWIHLs in the right parietal lobe. These findings led to a diagnosis of cerebral amyloid angiopathy and its related findings, including transient focal neurological episodes (TFNE) and DWIHLs, and antiplatelet medication was stopped. In clinical settings, although it is challenging to distinguish TFNE of hemorrhagic origin from cerebral ischemic symptoms, including transient ischemic attacks, this case suggests that even when elderly patients with transient neurological symptoms present with cortical DWIHLs, paramagnetic-sensitive MRI should be performed to check for cSS around the DWIHLs.

Efficacy and safety of tacrolimus as long-term monotherapy for myasthenia gravis.

The objective was to evaluate the long-term efficacy and safety of tacrolimus monotherapy in myasthenia gravis (MG) patients. Immunosuppressive drug-naïve MG patients were administered tacrolimus, followed by thymectomy in some of the cases according to the clinical guideline for MG. Additional aggressive immunosuppressive therapies were allowed if the patients without thymectomy did not achieve minimal manifestation (MM) or better status after 3 weeks of tacrolimus administration or in the thymectomized patients by 1-2 weeks after the operation (i.e., 1st evaluation). Of all 14 patients included in this study, 8 of them (57%) achieved MM or better status at the 1st evaluation, and the remaining 6 (43%), who had failed to gain MM or better status at the 1st evaluation, also achieved MM or better status with 1 course of aggressive immunosuppressive therapy. The quantitative MG (QMG) scores, MG-Activities of Daily Living (ADL) scales, and anti-acetylcholine receptor (AchR) antibody levels were significantly decreased at 6 months and maintained thereafter. At the end of the follow-up period (41-70 months), all patients were in MM or better status. None of the patients experienced severe adverse effects. Our small preliminary study indicates that long-term tacrolimus monotherapy is possibly effective and safe for MG patients.

A case of MOG antibody-positive bilateral optic neuritis and meningoganglionitis following a genital herpes simplex virus infection.

BACKGROUND: Myelin oligodendrocyte glycoprotein (MOG) antibody-positive optic neuritis (ON) and myelitis are recognized as important differential diagnosis of aquaporin-4 (AQP4) antibody-positive neuromyelitis optica (NMO)/NMO spectrum disorder (NMOSD). Similar to NMO/NMOSD associated with AQP4 antibodies, preceding infections have been reported in patients with MOG antibody-positive ON. This is the first report of bilateral ON following a herpes simplex virus (HSV) infection associated with a positive MOG antibody. CASE PRESENTATION: A 41-year-old man who initially presented with genital herpes developed allodynia in the Th2-Th5 and Th8-L2 areas, urinary retention, and painful visual loss in the left eye. Ophthalmological evaluation and brain magnetic resonance imaging (MRI) revealed bilateral ON. A spinal MRI showed leptomeningeal enhancement from the thoracic to lumbar vertebrae and abnormal enhancement of the L3 to S3 dorsal root ganglia without a change in intramedullary signals. Following treatment with acyclovir and steroid pulse, he fully recovered. Serum anti-AQP4 antibodies were negative, but anti-MOG antibodies were positive. Finally, he was diagnosed with MOG antibody-positive bilateral ON and meningoganglionitis following an HSV infection. CONCLUSION: Our case supports a relationship between anti-MOG antibodies and ON triggered by an HSV infection. Clinicians should thus consider testing for MOG antibodies in patients with post-infectious neurological symptoms due to an HSV infection.

Leptomeningeal Collaterals Strongly Correlate with Reduced Cerebrovascular Reactivity Measured by Acetazolamide-challenged Single-photon Emission Computed Tomography Using a Stereotactic Extraction Estimation Analysis in Patients with Unilateral Internal Carotid Artery Stenosis.

Objective To assess the correlation between the angiographic appearance of cerebral collateral pathways or the degree of internal carotid artery stenosis (ICAS) and reduced cerebrovascular reactivity (CVR) estimated by single-photon emission computed tomography (SPECT) image analysis in patients with unilateral ICAS. Methods A retrospective analysis was performed in 42 patients with unilateral ICAS who underwent cerebral angiography and acetazolamide-challenged SPECT of the brain. Cerebral blood flow quantitation was performed using the quantitative SPECT/dual-table autoradiography method. The CVR in the middle cerebral artery (MCA) territory was evaluated using the stereotactic extraction estimation based on the Japanese extracranial-intracranial bypass trial (SEE-JET) program and classified as reduced (<18.4%) or non-reduced (≥18.4%). Angiographic collateralization was classified as circle of Willis (type 1), extracranial-intracranial (type 2), and leptomeningeal (type 3). The degree of ICAS was defined as severe (≥70% stenosis) or non-severe (<70%). Results Eight patients showed reduced CVR, including 6 (46%) of 13 with type 3 collaterals and 2 (7%) of 29 without type 3 collaterals (p=0.006). In contrast, type 1 and type 2 collaterals and severe ICAS were not significantly associated with reduced CVR. Conclusion In patients with unilateral ICAS, leptomeningeal collaterals are strongly correlated with reduced CVR in the MCA territory, which presumably increases the risk of cerebral hyperperfusion after carotid artery stenting (CAS). Therefore, these findings may be clinically applicable to the perioperative management of CAS.

Thymoma-associated Progressive Encephalomyelitis with Rigidity and Myoclonus (PERM) with Myasthenia Gravis.

We report a case of a 72-year-old woman who initially presented with symptoms of bulbar myasthenia and was positive for anti-acetylcholine receptor antibodies. She subsequently developed painful muscle spasms, myoclonus, and stiffness. Thymoma was detected, and both anti-glycine receptor and anti-glutamic acid decarboxylase antibodies were found. She was diagnosed with thymoma-associated progressive encephalomyelitis with rigidity and myoclonus (PERM). She experienced marked improvement after thymectomy followed by plasma exchange and intravenous immunoglobulin and prednisolone. This case suggests that thymectomy followed by sufficient immunosuppression may be useful in the treatment of thymoma-associated PERM. Myasthenia gravis may develop in thymoma-associated PERM patients.

Rapidly progressive psychotic symptoms triggered by infection in a patient with methylenetetrahydrofolate reductase deficiency: a case report.

BACKGROUND: Methylenetetrahydrofolate reductase (MTHFR) deficiency is a rare inborn error of metabolism inherited in autosomal recessive pattern and is associated with a wide spectrum of neurological abnormalities. CASE PRESENTATION: We herein describe a 15-year-old boy with MTHFR deficiency who presented with a slowly progressive decline of school performance and a spastic gait. Rapidly deteriorating psychosis and repetitive seizures triggered by a febrile infection prompted neurological investigation. He had significantly elevated total plasma homocysteine and urinary homocystine levels, as well as a decreased plasma methionine level. Brain magnetic resonance imaging (MRI) revealed leukoencephalopathy. DNA gene sequencing showed c.446_447 del GC ins TT and c.137G > A, and c.665C > T heterozygous mutations in the MTHFR gene of the patient. Oral administration of betaine drastically improved his clinical symptoms within a few months. After 8 months of treatment, his total plasma homocysteine level moderately decreased; and the plasma methionine concentration became normalized. Furthermore, the white matter lesions on MRI had disappeared. CONCLUSION: This patient demonstrates the possibility that MTHFR deficiency should be considered in mentally retarded adolescents who display an abnormally elevated plasma level of homocysteine in association with progressive neurological dysfunction and leukoencephalopathy. Febrile infections may be an aggravating factor in patients with MTHFR deficiency.

Natalizumab is Effective for the Treatment of Relapsing-remitting Tumefactive Multiple Sclerosis.

We herein report the case of a 57-year-old woman presenting with a biopsy-proven tumefactive demyelinating lesion as her first clinical event. Subsequently, she displayed a relapsing-remitting course with recurrence of large demyelinating lesions exceeding 2 cm in diameter rather than the small ovoid lesions characteristic of multiple sclerosis. Administration of interferon beta did not suppress the disease activity. Finally, treatment with natalizumab, which is a humanized monoclonal antibody against the cell-adhesion molecule α4-integrin, was initiated, resulting in clinical and radiological stabilization. Our experience here suggests that natalizumab may be an effective therapeutic option for relapsing-remitting tumefactive multiple sclerosis with high disease activity.

Endovascular treatment of sphenoid wing dural arteriovenous fistula with pure cortical venous drainage.

Curative endovascular treatment of sphenoid wing dural arteriovenous fistula (dAVF) with pure cortical venous drainage is challenging because of its rarity, lack of accessible dural sinus for transvenous embolization (TVE), and proximity of skull base vital regions. Direct surgery to disconnect venous reflux has been favored. We report the curative endovascular treatment of two sphenoid wing dAVFs with pure cortical venous drainage. One patient revealed complete obliteration of dAVF by a single session of transarterial embolization (TAE). As part of strategic TAE for this complex dAVF, we used a novel approach to create a complete flow-arrest condition in which coils and an occlusion balloon were combined. A liquid agent was then injected across the pathological fistula and into the parent venous apparatus, thereby occluding the lesion. The other patient was treated with percutaneous TVE after TAE was unsuccessful. With a specific strategy and appropriate devices, the microcatheter was successfully introduced through sigmoid sinus, transverse sinus, superior sagittal sinus, and refluxing cortical vein by puncture of the jugular vein. Coils were deployed at the venous side of the fistula, resulting in successful obliteration of the dAVF. Sphenoid wing dAVF with pure cortical venous drainage could be curable by endovascular treatment with proper strategy and instruments when anatomical condition permits.

The first Japanese patient with variant Creutzfeldt-Jakob disease (vCJD).

Eleven years after a brief visit to some European countries, a 48-year-old Japanese man developed writing difficulty, irritability and general fatigue. Then he complained of dysesthetic pains in his legs, for which benzodiazepines were prescribed. However, at the time pulvinar sign was retrospectively confirmed on brain MRI. Eighteen months after the onset, his gait became ataxic with rapid deterioration of mental status over the following several months. Thirty-one months after the onset, he became akinetic and mute with periodic synchronous discharges on EEG, and died at the age of 51. The total clinical course was approximately 43 months. Pathological examination revealed the characteristic alterations of spongiform encephalopathy, severe in the thalamus, moderate but widely spread in the cerebral cortices, and moderate in the cerebellum. Abundant amyloid plaques were easily identified in the cerebral cortex and the cerebellum on HE staining. Immunohistochemistry for abnormal prion protein (PrP(sc)) confirmed amyloid plaques in several forms, such as florid, uni- and multi-centric plaques as well as perineuronal and periaxonal deposits in the basal ganglia and synaptic patterns in the thalami. A Western blotting study identified type 2B protease-resistant PrP. This is the first Japanese patient who was definitely diagnosed as variant Creutzfeldt-Jakob disease (vCJD). The pathological findings were similar to those of previous reports of vCJD in the UK. However, the changes were much more severe both in degree and distribution, probably due to a longer duration of the illness than those in the UK.

Hyperbaric oxygen combined with intravenous edaravone for treatment of acute embolic stroke: a pilot clinical trial.

The efficacy of hyperbaric oxygen (HBO) therapy combined with intravenous edaravone (free radical scavenger) administration was prospectively investigated in patients with acute embolic stroke involving the anterior cerebral circulation. Patients with acute embolic stroke in the anterior cerebral circulation admitted within 48 hours of onset from August 2001 to March 2002 with National Institutes of Health Stroke Scale (NIHSS) scores on admission of 5 or more were assigned randomly to HBO and control groups. The HBO group underwent HBO therapy combined with intravenous edaravone administration for 7 days, whereas the control group received only conventional treatment. The primary endpoint was the modified Rankin Scale score at 90 days (favorable outcome, score 0 or 1). The secondary endpoint was the NIHSS score at 7 days. Analysis was carried out by intention to treat. Six of the 19 patients in the HBO group, but only one of the 19 patients in the control group, had favorable outcomes at 90 days (p < 0.05), although NIHSS score at 7 days did not differ significantly between the two groups. HBO therapy combined with intravenous edaravone administration appears to be effective for the treatment of patients with acute embolic stroke in the anterior cerebral circulation.

[Ischemic stroke in a young patient with methylephedrine addiction: a case report].

We report a case of a young patient who had an ischemic stroke due to methylephedrine addiction. A 39-year-old man was admitted to our hospital because of right hemiplegia and persistent numbness. Brain diffusion-weighted magnetic resonance images demonstrated multiple hyperintensity spots in the deep and superficial borderzone area of the left hemisphere. The patient had no obvious diseases that might have caused ischemic stroke, including potential cardiac sources of embolism, vasculopathy of the cerebral artery, or abnormalities of blood coagulation. However, we found that the patient had started to abuse methylephedrine at the age of 20 years old, and we suspected that drug abuse might have caused his ischemic stroke. Although previous reports have associated ischemic stroke with ephedrine, no reports have related this condition to methylephedrine. However, our case suggests that methylephedrine abuse may cause ischemic stroke.

Successful stenting seven days after atherothrombotic occlusion of the intracranial internal carotid artery.

PURPOSE: To report a case of successful stenting after a subacute stroke. CASE REPORT: A 75-year-old man presented with sudden onset of right-sided weakness and difficulty speaking. Imaging revealed an occlusion of the left petrous to lacerum internal carotid artery (ICA) segment and slightly decreased cerebral blood flow in the left hemisphere; there were stenoses of the ostial and cavernous ICA segments on the right. On the seventh day after the stroke, he underwent protected carotid angioplasty of the left intracranial ICA occlusion to reduce the high risk of ischemic stroke owing to bilateral disease. An external arteriovenous shunt was established with an occluding balloon in the proximal ICA and a filter in the femoral vein. After protected balloon dilation of the ICA occlusion, a 3.5 x 18-mm balloon-expandable coronary stent was deployed across the residual stenotic segment. An intraluminal filling defect of the petrous ICA segment suggested an arterial dissection or intraluminal thrombus, so another 2 coronary stents were deployed. Macroscopically visible materials were captured in the filter. The patient had a good clinical course and was discharged without neurological deficits on the twelfth day after the stroke. Angiography at 3 months confirmed no restenosis of the stented vessel. CONCLUSION: This experience suggests that short atherothrombotic intracranial ICA occlusions can be opened in the subacute stroke stage without distal migration of thrombi under proximal protection and flow reversal.